Venous supply of head, neck and face

1. DR.USHA HATHGAIN ,MDS
ORAL & MAXILLOFACIAL SURGERY

2. OBJECTIVE
• Enlist the major veins supplying head and neck.
• To study the course & position of the veins of head & neck.
• To understand path of spread of infection via venous system&
its protection while performing surgeries of that area.

3. CONTENTS
 Introduction
 Classification of veins of head, neck ,face& brain.
 Veins of neck & its applied- External jugular v
Anterior jugular v
Internal jugular v
Lingual v
Subclavian v
 Veins of exterior head & neck & its applied.-
Supratrochlear v
Supraorbital v
Facial v
Superficial temporal v
Maxillary v
Retromandibular v
Posterior auricular v
Occipital v
Pterygoid venous plexus.
 Veins of brain- diploic v
Cerebral v
Dural venous sinus
Cavernous sinus & applied
Meningeal vein
Emissary vein
Sinus pericranii
Vascular malformation.

4. INTRODUCTION
 Veins are blood vessels that brings blood back to heart.
 Carry deoxygenated blood , except –Pulmonary &
Umbilical veins.
 Veins are classified as- VEINS
SUPERFICIAL DEEP V COMMUNICATING PULMONARY SYSTEMIC V
V (PERFORATOR)V V

5. Neck Exterior of head & face Brain
External jugular
Anterior jugular
Internal jugular
Subclavian
Brachiocephalic
Supratrochlear vein
Supraorbital vein
Facial vein
Superficial temporal vein
Maxillary vein
Pterygoid venous plexus
Retromandibular vein
Posterior auricular vein
Occipital vein
Diploic veins
Cerebral veins
Dural venous sinuses
Meningeal veins
VEINS OF HEAD,FACE,NECK &BRAIN
NECK VEINS FACIAL VEINS BRAIN & MENINGEAL SCALP/EMISSARY
VEINS VEINS

6. VEINS OF NECK
Superficial Veins Deep Veins
-External Jugular -Internal Jugular
-Anterior Jugular

7. EXTERNAL JUGULAR VEIN
 Draining areas-scalp and face, also
some deeper parts.
 ORIGIN- Formed by union of posterior
division of retromandibular vein with
posterior auricular Vein.
 Begins near mandibular angle just
below or in parotid gland and drains in
subclavian vein.
 Covered by platysma ,superficial fascia
and skin, and is separated from
sternocleidomastoid by deep cervical
fascia.
 SURFACE ANATOMY-Usually visible as
it crosses sternocleidomastoid obliquely.
Can be seen by effort blowing of mouth
closed.

8. TRIBUTARIES OF EXTERNAL JUGULAR VEIN
 Posterior external jugular
vein.
 Transverse cervical vein.
 Suprascapular vein.
 Anterior jugular veins.
 A branch from internal
jugular in the parotid.
 Occasionally joined by
occipital vein.

9. APPLIED-

10. ANTERIOR JUGULAR VEIN
 ORIGIN- Arises near the hyoid bone from
confluence of superficial submandibular
veins.
 Descends between midline and anterior
border of sternocleidomastoid. Turning
laterally , low in neck, deep to
sternocleidomastoid but superfi cial to
infrahyoid strap muscles.
 It joins either the end of external jugular
vein or may enter the subclavian vein
directly.
 Usually two anterior jugular veins, united
just above the manubrium(sternum) by a
large transverse jugular arch, the
VENOUS JUGULAR ARCH.
 They have no valves .

11. INTERNAL JUGULAR VEIN
 ORIGIN-Begins at the cranial base in the
posterior compartment of the jugular
foramen, where it is continuous with the
sigmoid sinus.
 Immediately below jugular foramen ,it is
widened to form superior bulb of IJV
contained in jugular fossa.
 Located posterior to internal carotid artery.
 At its lower end , at the junction with
subclavian v , IJV is again widened to form
inferior bulb.
 Posterior to sternal end of clavicle , IJV
combines with subclavian v to form
BRACHEOCEPHLIC VEIN.
 SURFACE ANATOMY-IJV is represented by
surface projection by broad band drawn
from lobule of ear to median end of clavicle.
 DRANING AREAS- skull, brain, superficial
parts of face and much of the neck.

12.  Relations of the Internal
Jugular Vein
 ■■ Anterolaterally: The skin, fascia,
sternocleidomastoid and parotid salivary gland.
Its lower part is covered by sternothyroid ,
sternohyoid, and Omohyoid. Higher up, it is crossed
by the stylohyoid , the posterior belly of the
digastric, and the spinal part of the accessory nerve.
 The chain of deep cervical lymph nodes runs
alongside the vein.
 ■■ Posteriorly: The transverse processes of the
cervical vertebrae, levator scapulae, scalenus
medius, the scalenus anterior, the cervical plexus,
the phrenic nerve, the thyrocervical trunk, the
verteberal vein, and the first part of the subclavian
artery
. On the left side, it passes in front of the thoracic
duct.
 ■■ Medially: Above lie the internal carotid
artery and 9th, 10th, 11th, and 12th cranial nerves.
Below lie the common carotid artery and the vagus
nerve.

13. Tributaries of the Internal
Jugular Vein
 Inferior petrosal
sinus
 Facial vein
 Pharyngeal veins
 Lingual vein
 Superior thyroid
vein
 Middle thyroid vein

14. APPLIED
Jugular phlebectasia in children.

16. LINGUAL VEIN
 Drains tongue& sublingual region.
 3branches-Dorsal lingual v
Deep lingual v IJV
Sublingual v

17. APPLIED
 LINGUAL VARICOSITY-Abnormally , dilated ,
tortuous v produced by prolonged increase
intraluminal pressure. Small purpulish ,blue-black
round swellings under tongue with age & are known as
‘Caviar lesions’.
 No treatment is indicated for lingual varices . Care
needs to be excised when performing surgery in this
region due to high vascularity of area.

18. SUBCLAVIAN VEIN
 It is a continuation of axillary
vein at the outer border of the 1st
rib .
• It joins IJV to form the
brachiocephalic vein, and it
receives the EJV. In addition, it
often receives the thoracic duct
on the left side and the right
lymphatic duct on the right.
Relations
 Anteriorly: The clavicle
 Posteriorly: The scalenus anterior
muscle and the phrenic nerve
 Inferiorly: The upper surface of the
1st rib

19. VEINS OF EXTERIOR HEAD & FACE
SUPRATROCHLEAR VEIN
 ORIGIN-Starts on
forehead from
venous network
which connects to
the frontal
tributaries of
superficial temporal
vein.
 Joins supra-orbital v
to form facial v near
medial canthus.

20. SUPRAORBITAL VEIN
 ORIGIN-Begins on the
forehead where it
communicates with frontal
branch of superficial
temporal v.
 Runs downward superficial to
frontalis muscle& joins
frontal v at medial angle of
orbit to form ANGULAR V .
Passes under orbicularis oculi.
 A branch passes through
supraorbital notch to join
superior opthalmic v . In
notch it receives veins from
frontal sinuses & frontal
dipole.

21. FACIAL VEIN
 DRINING AREAS- superficial face.
 ORIGIN-Commences at side on
root of nose& lies behind facial
artery.
 Formed by union of supraorbital &
supratrochlear veins at medial
canthus to form ANGULAR VEIN.
 Communicate with cavernous sinus
through opthalmic v or supraorbital
vein. After receiving the
supratrochlear and supraorbital
veins, it travels obliquely downwards
by side of the nose, passes under
zygomaticus major, risorius and
platysma,descends to the anterior
border and then passes over the
surfaceof masseter. It crosses the
body of the mandible, and runs
down in the neck to drain into the
internal jugular vein.

22. TRIBUTARIES
 Superior opthalmic vein.
 Veins of alae of nose.
 Deep facial vein ,from pterygoid
plexus.
 Inferior palpebral .
 Superior & inferior labial(drains
area of upper & lower lip).
 Buccinator (drains area of
cheek).
 Parotid & massetric vein( drains
areas from parotid & masseter).
 Below mandible it receives
submental, tonsillar ,external
palatine &submandibular vein.

23. APPLIED
 Facial vein have no valves &
connect to cavernous sinus by 2
routes –
 1.via opthalmic vein or
supraorbital vein.
 2.via deep facial vein to pterygoid
plexus& hence to cavernous sinus.
 Thus infective thrombosis of
facial vein may extend to
intracranial venous sinuses.
 CAVERNOUS SINUS
THROMBOSIS.

24. SUPERFICIAL TEMPORAL VEIN
 ORIGIN-Begins in a
widespread network joined
across scalp to contralateral
vein& with supratrochlear
,supraorbital,posterior
auricular& occipital veins,all
draining same network.
 Cross posterior root of
zygoma& enters parotid
gland to unite with maxillary
vein to form
RETROMANDIBULAR
VEIN.

25. MAXILLARY VEIN
 ORIGIN-Formed in
infratemporal fossa.
 It is confluence of vein
from pterygoid venous
plexus,passes back
between
sphenomandibular
ligament & neck of
mandible ,to enter
parotid gland & here it
unites with superficial
temporal to form
Retromandibular vein .

26. RETROMANDIBULAR VEIN
 ORIGIN-Formed by the union of maxillary
vein and superficial temporal vein.
 Leaving parotid gland divides into anterior
branch and posterior branch.
 Anterior branch joins facial vein.
 Posterior branch joins posterior auricular vein
to form external jugular vein.
 APPLIED-

28. POSTERIOR AURICULAR VEIN
•ORIGIN-Begins upon the side of neck,In
a plexus which communicates with
tributaries of occipital vein and temporal
veins.
•Descends behind auricula and joins
posterior division of retromandibular vein
to form EJV.
•APPLIED –
•Receives mastoid emissary veins from
sigmoid sinus.
Infection here canbe dangerous or fatal
from retrograde thrombosis of cerebellar
and medullary veins.

29. OCCIPITAL VEIN
•ORIGIN-Begins in
posterior network in scalp
, pierce the cranial
attachment of trapezius ,
turns into suboccipital
triangle & becomes deep.
•May follow occipital
artery .
• Join posterior auricular
& hence external jugular
vein.

30. PTERYGOID VENOUS PLEXUS
•ORIGIN-Placed partly between
temporalis & lateral pterygoid &
partly between two pterygoids.
•Anteriorly reaches from
maxillary tuberosity & superiorly
to the base of skull.
•Connects with facial vein
through deep facial vein & with
cavernous sinus through veins
that passes through sphenoidal
emissary foramen , foramen ovale
& lacerum.
•Its deep triutaries are connected
with middle minengeal vein.

31. • TRIBUTARIES-Sphenopalatine,
 deep temporal,
 pterygoid,
masseteric ,
buccal,
dental,
greater palatine
middle meningeal veins &
branchesfrom inferior
opthalmic vein.
• APPLIED-
• Needle track communications can also result in
infection to pterygoid plexus.
• PSAblock hematoma.
• Serve as a media for spread of external infection
to eye.

32. VEINS OF BRAIN
Diploic veins Cerebral veins Dural venous Meningeal
sinuses veins

33. DIPLOIC VEIN
 These veins occupy channels in dipole of
some cranial bones & are devoid of valves.
absent at birth begin to develop at about 2
yrs.
 Communicate with meningeal v,dural
sinuses& pericranial veins.
Diploic veins
Frontal Anterior posterior occipital
temporal temporal

34. CEREBRAL VEIN
Cerebral veins
EXTRNAL CEREBRAL INTERNAL CEREBRAL
VEIN VEIN
•Superior cerebral vein
•Middle cerebral vein
•Inferior cerebral vein
•Basal vein

35. CRANIAL VENOUS SINUSES
•These are spaces between endosteal &
meningeal layers of duramater.
•General features-
•Walls formed by duramater lined by
epithelium,muscular coat is absent.
•Have no valves.
•Receives 1. venous blood from
brain,meninges & bone
2.the CSF
•Major draining pathway from
brain,predominantly to IJV.
•Communicates with veins outside skull
through EMISSARY VEINS.These
connections helps to keep pressure of
blood in sinus constant.

36. DURAL VENOUS SINUSES
PAIRED UNPAIRED
Cavernous sinus Superior
saggital sinus
Superior
petrosal sinus
Inferior saggital
sinus
Inferior petrosal
sinus
Straight sinus
Transverse sinus Occipital sinus
Sigmoid sinus Ant. Cavernous
s
Sphenoparietal
sinus
Post. Cavernous
s
Middle
meningeal veins
Basilar plexus of
veins

37.  A

38. CLINICAL RELEVANCE
 Dural sinus thrombosis may lead to
haemorrhagic infractions with serious
consequences including epilepsy,
neurological deficits & death.
 Causes of dural venous sinus
thrombosis-
 Head & neck infection
 Head injury
 Skull fracture or intracranial
hematomas
 Most common thrombosed sinuses are-
Transverse sinus.
Cavernous sinus.
Superior saggital sinus.
 CLINICAL SYMPTOMS-
 Headache.
 Papilloedema.
 Impaired consciousness.
 Vomitting.

39. CAVERNOUS SINUS
•LOCATION-In middle cranial fossa ,on either
side of sphenoid bone.
•SIZE- 2cm long & 1cm wide.
•EXTENT-Anteriorly- superior orbital fissure.
Posteriorly - apex of petrous temporal .
Medially- pitutary above, shenoidal air
cells below.
Lateral-temporal lobe,uncus
Superior- optic chiasm.
•DRAINS INTO-1.Transverse sinus via superior
sinus & petrosal sinus.
2.IJV via inferior petrosal sinus &
venous plexus around int.carotid artery.
3.Pterygoid plexus via emissary
veins passing through foramen ovale.
4.Facial vein through superior
opthalmic vein.

40. ’ Tributaries:
– Superior and inferior opthalmic
veins
– Sphenoparietal sinus
– Inferior cerebral veins
– Superficial middle cerebral veins
– Central vein of retina
•Right & left commmunicate with
each other through intercavernous
sinus & basilar plexus of veins.
•Communications are valve less & bl.
Can flow in either direction.
’Contents of cavernous sinus
- carotid artery
- CN 3
- CN 4
- CN 5 (1stand 2nddivisions)
- CN 6

41. CAVERNOUS SINUS THROMBOSIS
DEFINATION-It is an infection leading to blood clot caused by
complication of an infection in the paranasal or central face area.
’Path:
– VENOUS OBSTRUCTION
– INVOLVEMENT OF CRANIAL NERVES
– SEPSIS
’ Venous obstruction:
– Proptosis (first beforeoedema & chemosis)
– Oedema of eyelids and bridge of nose
– Chemosis
– Dilatation and tortuosity of retinal veins
– Retinal hemorrhages
– Involvement of the contralateral eye – (48 hours)
– (anatomic communications betweenthe two cavernous sinuses)
– When pterygoid plexus is occluded along with sinus, - oedema of the
pharynx or tonsil
Involvement of cranial nerves
’ Ptosis - paralysis of oculomotor nerve (and edema)
’ Dilatation of pupil- third nerve and stimulation of sympathetic plexus
’ Decreased abduction (paralysis of abducens nerve)
’ Ophthalmoplegia - CN 3,4,6 (and oedema)
’ Loss of vision
’ Pain in region supplied by ophthalmic branch of 5th cranial nerve.
’ Bulb may also be fixed from orbital swelling
’ Retro-orbital pain and supra-orbital headache .

42.  Sepsis
 ’ Pyrexia
 ’ Rapid, weak, thready pulse
 ’ Chills and sweats
 ’ Delirium - meningitis supervenes terminally
 ’ Septic emboli to (1) lungs (2) kidney (3) spleen (4)
liver and various
 other parts of body.
Involvement of cranial nerves
’- Ptosis - paralysis of oculomotor nerve (and
edema)
’- Dilatation of pupil- third nerve and stimulation
of sympathetic plexus
’- Decreased abduction (paralysis of abducens
nerve)
’- Ophthalmoplegia - CN 3,4,6 (and oedema)
’- Loss of vision
’ -Pain in region supplied by ophthalmic branch of
5th cranial nerve.
’- Bulb may also be fixed from orbital swelling
’ -Retro-orbital pain and supra-orbital headache .

43. MENINGEAL VEINS
ORIGIN- begin from plexiform vessels in the dura mater and
drain into efferent vessels in the outer dural layer which connect with
lacunae associated with some of the cranial sinuses. They include the
middle meningeal and the diploic veins. Intracranial veins also
communicate
with extracranial vessels via emissary veins.
Middle meningeal vein (sinus)
ANTERIOR BRANCH POSTERIOR BRANCH

44. EMISSARY VEINS
.
Emissary veins traverse cranial apertures and make
connections between intracranial venous sinuses and
extracranial veins.
CLINICAL SIGNIFICANCE-
in determining the spread of infection from extracranial foci
to venous sinuses, for example, the spread of infection from
the mastoid to the venous sinuses or from the paranasal
sinuses to the cavernous sinus.
The following emissary veins have been recognized. A---
1.Mastoid emissary vein
2.Parietal emissary vein
3.Venous plexus of the hypoglossal canal
4.(posterior) Condylar emissary vein
5. A plexus of emissary vein(venous plexus of foramen ovale)
6. . A vein in the emissary sphenoidal foramen (of Vesalius)
connects the cavernous sinus with the pharyngeal veins and
pterygoid plexus
7. Internal carotid venous plexus
8. Petrosquamous sinus
9. Occipital emissary
10. . A vein may traverse the foramen caecum (which is patent
in about 1% of adult skulls) and connect nasal veins with the
superior sagittal sinus

45. SINUS PERICRANII
 A rare disorder characterized by a
congenital (or occasionally
acquired ) epicranial venous
malformation of scalp.
•There is an anomalous connections
between an extracranial blood-fi lled
nodule and an intracranial dural
venous sinus via dilated diploic and/or
emissary veins of the skull

46. VASCULAR MALFORMATIONS
Described as abnormalities of blood and
lymphatic vessels,vascular
malformation, like many hemangioma
are present at birth but do not undergo
proliferation and do not spontaneously
involute.
Do not 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.
Fail to show characterstic picture on
radiograph. MRI can indicate the
presence and extent of vascular
malformation.
TREATMENT: May be treated with
sclerotherapy as well as direct injections
of sodium morrhuate, boilling water,
alcohol & ethibloc.
Combined application of sodium
tetradecyl sulfate sclerotherapy &
conservative ablative surgery when large
lesions are involved.