The internal jugular vein is an important vessel that drains the head and neck region. It can be punctured to assess central venous pressure. Infection from the middle ear or cavernous sinus can spread to the internal jugular vein. The vein is also easily accessible for cannulation between the heads of the sternocleidomastoid muscle.

1. VENOUS DRAINAGE OF
FACE,HEAD AND NECK
Presented by
Sauvik Singha
1st year PG Student
Oral and Maxillofacial Surgery

2. Index
1.Introduction
2.Venous drainage of Face
3.Venous drainage of Neck
4.Venous drainage of Head
5.Surgical implications
6.Bibliography

3. 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

4. Structure of Vein
Veins are thin walled than arteries.
Large lumen.
Valves, maintain unidirectional blood flow.
3 concentric layers ( tunicae)
1) Tunica intima - (endothilial cells & internal
elastic lamina)
2) Tunica media –( contains muscle tissue, elastic
fibers, collagen , external elastic lamina)
3) Tunica adventitia – (elastic and collagen tissue,
muscle fibers)

5. Veins are classified as:
Superficial veins
Deep veins
Communicating veins
pulmonary veins
Systemic veins .
5

6. Artery vs. Vein
6

7. 7

8. VENOUS SYSTEM ,HOW DOES IT WORK?
8

9. -skin of nose,lips ,ears,nasal& alimentary mucosae,tongue,thyroid gland
& sympathetic ganglia. 9

10. All the venous drainage from the head and neck
terminate ????

11. Veins of head, face, neck and brain
Exterior of head Neck Brain
and face
• Supratrochlear *External Jugular *Diploic veins
• Supraorbital *Cerebral
vein
• Facial vein
• Superficial temporal *Anterior Jugular *DuralVenous
• Maxillary vein *Internal Jugular Sinuses
• Pterygoid Venous *Subclavian
plexus *Brachiocephalic
• Retromandibular
• Posterior auricular
• Occipital vein
11

12. Venous drainage of face

14. Supra trochlear vein
14

15. Supraorbital vein
15

16. Facial vein
16

17. Facial vein, tributaries
17

18. Superficial temporal
18

19. Maxillary vein
19

20. Retromandibular vein
20

21. Posterior auricular
21

22. Occipital vein
22

23. 23

24. a) PTERYGOID
Location:
Between lateral and
medial pterygoid
or
between temporal and
lateral pterygoid

25. Tributaries:
1. Sphenopalatine v
2. Deep temporal v
3. Pterygoid v
4. Masseteric v
5. Buccal v
6. Dental v
7. Greater palatine v
8. Middle meningeal v
9. Inferior opthalmic v

26. 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

27. 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

28. Veins of the neck
The word "jugular" refers to the throat or
neck.
It derives from the Latin
‘jugulum’
meaning throat or collarbone
28

30. External Jugular vein
• FORMED by ?

31. Tributaries
1.Posterior jugular vein
2.Anterior jugular vein
3.Transverse cervical vein
4.Suprascapular vein
• It drains into Subclavian
vein

32. Internal jugular vein
• It is a direct
continuation of the
sigmoid sinus
• Begins at Jugular
foramen and
• Ends behind sternal
end of clavicle
• Joins Subclavian vein
to form
Brachiocephalic vein

33. Tributaries
1.Inferior petrosal sinus
2.Common facial vein
3.Lingual vein
4.Pharyngeal vein
5.Superior thyroid vein
6.Middle thyroid vein
7.Occipital vein

34. Relation with its surroundings

35. Anterior jugular vein
35
Tributaries:
1. Skin
2. Superficial
tissues of
neck

36. 36
• Each subclavian vein is a
continuation of the axillary
vein
• runs from the outer
border of the first rib to
the medial border
of anterior scalene muscle.
• From here it joins with
the internal jugular vein to
form the brachiocephalic
vein
Subclavian vein

37. Brachiocephalic vein
• FORMED by ?
• Formed behind Sternoclavicular joint

38. Right Brachiocephalic vein
• 2.5 cm long
• Runs vertically downwards
• TRIBUTARIES are namely :
1.Vertebral vein
2.Internal thoracic vein
3.Inferior thyroid vein
4.First posterior intercostal vein

39. Left Brachiocephalic vein
• 6 cm long
• Runs obliquely downwards and to the right
behind the half of manubrium sterni
• TRIBUTARIES are namely :
1.Vertebral vein
2.Internal thoracic vein
3.Inferior thyroid vein
4.First posterior intercostal
5.Left superior intercostal
6.Thymic and pericardial veins

41. Superior vena cava
• FORMED by union of right and left
Brachiocephalic veins
• Formed at lower border of the right first costal
cartilage
• It pours blood into right atrium of the heart

42. Venous drainage of head

44. Dural Venous Sinuses
• They are blood-filled spaces situated between
the layers of the duramater,
• Lined by endothelium,
• Walls are thick and composed of fibrous
tissue.
• They have no muscular tissue.
• They have no valves.

45. • They receive blood from:
1.The Brain
2.The Meninges
3.Bones of the skull
• CSF is also poured in some of them.

46. Types of Dural sinuses
• There are 23venous sinuses, of which –
•8 are PAIRED
•7 are UNPAIRED

47. Paired
1.Cavernous sinus
2.Superior petrosal sinus
3.Inferior petrosal sinus
4.Transverse sinus
5.Sigmoid sinus
6.Sphenopalatine sinus
7.Petrosquamous sinus
8.Middle Meningeal sinus

48. Unpaired
1.Superior sagittal sinus
2.Inferior sagittal sinus
3.Straight sinus
4.Occipital sinus
5.Anterior
intercavernous sinus
6.Posterior
intercavernous sinus
7.Basilar plexus of veins

49. Superior and Inferior Petrosal sinus

50. • They are small and situated on the superior
and inferior borders of the petrous part of the
temporal bone on each side.
• Each superior sinus drains the cavernous sinus
into the transverse sinus.
• Each inferior sinus drains the cavernous sinus
into the internal jugular vein.

51. Transverse sinus

52. Transverse sinus
• They are paired and begin at the internal
occipital protuberance.
• The right sinus usually continuous with the
superior sagittal sinus.
• The left is continuous with the straight sinus.

53. Sigmoid sinus
53

54. Sigmoid sinus
• They are a direct continuation of the transverse
sinuses.
• Each sinus turns downward and medially and
grooves the mastoid part of the temporal bone.
• Here it lies behind the mastoid antrum.
• It then turns downward through the posterior part
of the jugular foramen to become continuous with
the superior bulb of the internal jugular vein.

56. Superior sagittal sinus
• It occupies the upper fixed border of the falx
cerebri.
• It begins in the front at the foramen cecum
where it receives a vein from the nasal cavity.
• It runs backward, grooving the vault of the
skull and at the internal occipital protuberance
it deviates to one side and becomes
continuous with the transverse sinus.

57. Superior sagittal sinus
• It communicates through small openings with 2
or 3 venous lacunae on each side.
• Numerous arachnoid villi and granulations
project into these lacunae which also receive the
diploic; emissary and meningeal veins.
• It receives the superior cerebral veins . At the
internal occipital protuberance it is dilated to
form the confluence of the sinuses which is
connected to the opposite transverse sinus and
receives the occipital sinus.

58. Inferior sagittal sinus
• It occupies the free lower margin of the falx
cerebri.
• It runs backward and joins the great cerebral
vein which is formed by the union of the two
internal cerebral veins at the free margin of
the tentorium cerebelli to form the straight
sinus.
• It receives cerebral veins from the medial
surface of the cerebral hemisphere.

59. Straight sinus

60. Straight sinus
• It occupies the line of junction of the falx
cerebri with the tentorium cerebelli.
• It is formed by the union of the inferior
sagittal sinus with the great cerebral vein.
• It ends by turning to the left ( sometimes to
the right ) to form the transverse sinus.

61. Occipital sinus

62. Occipital sinus
• It is a small sinus occupying the attached
margin of the falx cerebelli.
• It communicates with the vertebral veins near
the foramen magnum.
• Superiorly it drains into the confluence of
sinuses.

63. Cavernous sinus

64. Cavernous sinus
• situated in the middle cranial fossa on each
side of the body of the sphenoid bone.
•
Each sinus extends from the superior orbital
fissure in front to the apex of the petrous part
of the temporal bone behind.

65. The 3rd ; 4th cranial
nerves and the
ophthalmic &
maxillary divisions of
the trigeminal nerve
run forward in the
lateral wall of this
sinus.
The internal carotid
artery, its
sympathetic nerve
plexus and abducent
nerve run forward
through it.

66. Tributaries
• It recieves blood from the
• ORBIT, BRAIN and the MENINGES
• From ORBIT:
1.Superior opthalmic vein
2.Inferior opthalmic vein
3.Central vein of retina

67. • From the BRAIN:
1.Superficial middle cerebral vein
2.Inferior cerebral vein from the temporal lobe
• From the MENINGES:
1.Sphenopalatine sinus
2.Frontal trunk of the middle meningeal vein

68. Communications
1. Transverse sinus through
superior petrosal sinus
2. Internal jugular vein trough
inferior petrosal sinus
3. Pterygoid plexus through
emissary veins
4. Facial vein through superior
opthalmic vein
5. Cavernous sinus of opposite
side through anterior and
posterior intercavernous
sinus.

69. EMISSARY VEINS
• Cranial venous
sinuses
communicate
with veins
outside the
skull through
EMISSARY
VEINS
• These
comminication
s help to keep
the pressure of
blood in the
sinuses
constant

71. Diploic Veins
• The diploic veins are found in the skull, and
drain the diploic space.
• This is found in the bones of the vault of the
skull, and is the marrow-containing area of
cancellous bone between the inner and outer
layers of compact bone.
• The diploic veins drain this area into the dural
venous sinuses

72. Surgical Implications

73. Facial vein
• Applied Importance:
• 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
and hence to cavernous sinus.
• Thus infective thrombosis of facial vein
may extend to intracranial venous
sinuses.
73

74. RMV
74
• Formation of the RMV by union of the superficial temporal
vein and maxillary vein mostly occurs at a level higher than
the passage of the main trunk and branches of the FN,
where they laterally pass to the vein.
• In open surgical reduction of mandibular condyle fractures,
the FN and its branches can be localized by using the
superficial temporal veins and the RMVs as a guide, even in
abnormal course of the nerve.

75. Lateral view of right facial nerve (FN) giving superior division (SD) and inferior division
(ID); each of them pass through a separate ring in the retro-mandibular vein (RMV).
75

76. 76
Ronald A. Bergman, PhD
Adel K. Afifi, MD, MS
Ryosuke Miyauchi, MD

77. 77
In 13%, major divisions (temporal and facial) are independent;
in 11%, anastomoses occur between rami of the temporal division;
in 22%, connections occur between adjacent rami from the major
divisions;
in 21%, anastomoses representing a composite of those in the11% and
22% categories occur;
in 12%, proximal anastomoses occur within the temporal component,
as well as distal interconnection between the latter and the cervical
component;
in 9%, two anastomotic rami connect the buccal divisin of the cervical to
the zygomatic part of the temporal;
in 5%, a transverse ramus, from the trunk of the nerve, contributes to
the buccal ramus formed by anastomosis between the two major
divisions;
in 7% richly plexiform communications occur, especially within the
temporal portion of the nerve.

78. Communications of the Pterygoid plexus
1. With Inferior opthalmic vein through the inferior
orbital fissure
2. With Cavernous sinus through emissary veins
3. With facial vein through the deep facial vein

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

80. Abnormaly dilated, tortuous veins produced by
prolonged, increase intraluminal pressure. Small
purplish or blue-black round swellings under the
tongue with age and are known as “caviar lesions”
No treatment is indicated for lingual varices..
Lingual varicosity
80

81. EJV
• EJV is examined to assess the venous pressure; the
right atrial pressure is reflected in it because of
absence of valves.
• Vein is visible through skin and can be made more
prominent by blowing with mouth and nostrils closed.
• Normal JVP is 5 to 8 cm.
• Vene puncture performed on this vein
• Surgical division of sternocleidomastoid muscle
requires special care of the vein
• Increased venous pressure indicates congestive cardiac
failure

82. Visualization (LEWIS METHOD)
The veins of the neck, viewed from in
front.
The patient is positioned under 45°,
and the filling level of the jugular
vein determined. Visualize the internal
jugular vein when looking for the
pulsation. In healthy people, the filling
level of the jugular vein should be less
than 3 centimetres vertical height
above the sternal angle.
JVP
82

83. Jugular venous pulse (JVP)
• Determine activity of
atrium
• Seen better then felt
• Preferable over EJV
• Elevation of JVP
indicative
of cardiac failure

84. A man with severe
congestive cardiac failure
with marked jugular
venous distension.
External jugular vein
marked by arrow.
84

85. IJV
 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

86.  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
 In congestive cardiac failure, venous
pressure is markedly increased, the IJV is
dilated and engorged with blood.

87. • The deep cervical
lymph node lie on
IJV. These nodes
become adherant
to veins in
malignancy or in
T.B. Therefore
during such
operations the vein
is also resected.

88. Applied anatomy:
1. Special care required
to
preserve the vein
during
surgical treatment
of wry neck
AJV

89. Jugular phlebectasia in children
• Jugular phlebectasia is a congenital dilatation of
jugular vein which appears as a soft, compressible
mass in the neck only during straining or crying. It
should be differentiated from laryngocele, cysts and
tumors of neck which may also appear during
straining.
• Ultrasonography (US) and computerized tomography
(CT) are diagnostic methods to distinguish the
pathology
• More common in internal jugular vein.
89

90. Dural sinus thrombosis
may lead to haemorrhagic infarction with serious
consequences including epilepsy, neurological deficits
and death.
Common causes of dural venous sinus thrombosis
include head and neck infections, head injury,skull
fractures or intracranial hematomas either by direct
compression of the sinus or endothelial damage within
the sinus can cause the activation of coagulation system
resulting in sinus occlusion.
90

91. 91
Brain cells contain an abundance of thromboplastin that is
released after injury inducing an hypercoagulable state
leading to destruction of platelets & erythrocytes followed by
thrombus formation.
Most common thrombosed sinuses are tranSverse,cavernous
& superior saggital sinus
Clinical symptoms
headache, papilloedema, impairedconsciousness, vomitting.

92. Metastasis of tumour cells to dural sinuses
Tha basilar and occipital sinuses communicate through the
foramen magnum with the internal venous plexuses.
Because these venous channels are valveless,
compression of the thorax, abdomen, or pelvis as occurs
during heavy coughing and straining may force venous
blood from these regions into vertebral venous system and
from it into dural venous sinuses.
As a a result, pus in the abscesses and tumour cells in
these regions may spread to vertebrae and brain.
92

93. Cavernous sinus thrombosis

94.  Thrombosis caused by sepsis in the danger
area of face, nasal cavity, paranasal sinuses give
rise to :
Nervous symptoms:
1) severe pain in the eye and forehead in the
area of distribution of opthalmic nerve.
2) Involvement of 3rd, 4th and 6th nerve resulting
in paralysis of muscle supplied.
94

95. 95
Venous symptoms:
1)Marked edema of eyelid, cornea & exopthalmos due to
congestion of orbital vein.
Carotid and cavernous communication: because of
peculiar relationship of cavernous sinus to internal carotid
artery a communication may occur between the two as a
result of injury.
When this happens the arterial pressure is communicated
through the sinus to vein of orbit & as a result the eye
become prominent & pulsate with each heart beat(
pulsating exopthalmos)

96. Emissary veins are connection between the extracranial scalp veins and
the diploic and intracranial venous systems. These veins are valveless
and therefore can transmit infection from the extracranial to the
intracranial compartment.
The meningeal veins are epidural veins that lie within the dura draining
the falx cerebri, the tentorium, and the cranial dura. They run in shallow
grooves on the inner table of the skull to communicate with the dural
sinuses or traverse extracranially to the pterygoid plexus in the deep
face or vertebral plexus around the cervical spine.
The diploic veins are small irregular endothelial-lined channels coursing
between the inner and outer tables of the skull. These communicate
with the extracranial venous system, the meningeal veins, and the dural
sinuses. They are rarely seen using angiography unless enlarged, as in
the case of an arterial-venous malformation.
Communication between extracranial and intracranial veins
96

97. 97
Danger triangle of the face
consists of the area from the corners
of the mouth to the bridge of
the nose, including the nose
and maxilla
The presence of loose areolar tissue
containing the emissary veins allows
the spread of retrograde infections
from the nasal area to spread to
the brain causing
cavernous sinus thrombosis,
meningitis
brain abscess.

98. • Sinus pericranii (SP) is a rare disorder
characterized by a congenital (or occasionally,
acquired) epicranial venous malformation of
the scalp.
• Sinus pericranii is an abnormal
communication between the intracranial and
extracranial venous drainage pathways.
• Treatment of this condition has mainly been
recommended for aesthetic reasons and
prevention of hemorrhage.
Sinus pericranii
98

99. Vascular malformations
Described as abnormalities of
blood and lymphatic vessels,
vascular malformations, like
many hemangiomas, are
present at birth but do not
undergo proliferation and do
not spontaneously involute.
• Donot regress with age and
may be associated with
severe or life threatening
haemorrhage.
• A large venous malformation
appears as bluish , soft,
compressible lesion,no bruit
or pulsation is present.
99

100. • TREATMENT: May be treated with
sclerotherapy as well as direct injections of
sodium morrhuate, boiling water, alcohol &
ethibloc.
• Combined application of sodium tetradecyl
sulfate sclerothearpy & conservative ablative
surgery when larger lesions are involved.
100

101. Telangiectasias or angioectasias are small
dilated blood vessels near the surface of the skin or
mucous membranes,
measuring between 0.5 and 1 millimeter in
diameter.
They can develop anywhere on the body but are
commonly seen on the face around the nose,
cheeks, and chin.
Some telangiectasia are due to developmental
abnormalities that can closely mimic the behaviour
of benign vascular neoplasms.
They may be composed of abnormal aggregations
of arterioles, capillaries, or venules.
Telangiectasia
101

102. • Telangiectasias on the face are often treated with
a laser.
• Laser therapy uses a light beam that is pulsed
onto the veins in order to seal them off, causing
them to dissolve.
• These light-based treatments require adequate
heating of the veins.
• These treatments can result in the destruction
of sweat glands, and the risk increases with the
number of treatments.
102

103. 103
central venous catheter

104. ("central line", "CVC", "central venous line" or "central
venous access catheter")
is a catheterplaced into a large vein
in the neck (internal jugular vein),
chest (subclavian vein or axillary vein) or
groin (femoral vein).
It is used to administer medication or fluids, obtain blood
tests (specifically the "mixed venous oxygen saturation"), and
directly obtain cardiovascular measurements such as
the central venous pressure.
104

105. 105
Indications and uses
Monitoring of the central venous
pressure (CVP) in acutely ill patients to quantify
fluid balance
Long-term Intravenous antibiotics
Long-term Parenteral nutrition especially in
chronically ill patients
Long-term pain medications
Chemotherapy

106. 106

107. Venepuncture
• Indication: To introduce or replace fluids in
circulation
• Site: Veins of forearm, ankle, or feet
• Complications:
1.Overloading
2.Thrombophlebitis
3.Haematoma
4.Infection
5.Air embolism

108. Venesection
• Indication: To replace fluids when
venepuncture is not possible and to measure
CVP
• Site: Saphenous vein over ankle and cephalic
vein

109. Pterygo-maxillary dysjunction

110. PSA Nerve Block

111. Air Embolism
• External jugular vein pierces the investing
layer of deep cervical fascia
• The margins of the vein get adherent to the
fascia
• So, if the vein gets cut, it can not close and air
enters into it causing air embolism

112. Vein grafting

113. 113

114. Bibliography
• B.D. Chaurasia’s Human Anatomy Volume 3
• Gray’s Textbook of Anatomy
• Hine, Levy, Shafer’s Textbook of Oral
Pathology
• Hutchinson’s Textbook of Medicine
• Peterson’s Textbook of Oral Surgery
• Internet

115. Thank You