VENOUS DRAINAGE

OF
HEAD AND NECK

PRESENTER:
Dr. Ashish Soni
1. Veins
CONTENTS
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
6. Venous sinuses
7. Communication between venous sinuses & extracranial veins
8. CVP
9. Diseases of veins
10. 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 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)
Differences between arteries and veins
 Arteries Veins

Oxygen Concentration: Arteries carry oxygenated blood (with the Veins carry deoxygenated blood (with the
exception of the pulmonary artery and exception of pulmonary veins and umbilical
umbilical artery). 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 Thin, elastic muscle layer with semilunar valves
pressure of the blood flowing through the that prevent the blood from flowing in the
arteries. opposite direction.

Overview: Arteries are red blood vessels that carry blood Veins are blue blood vessels that carry blood
away from the heart. resistance vessels 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 heart
2) Cushion associated arteries from jaw
movements(periarterial plexus)
3) Protect against extensive intracranial pressure.
 Classification of veins
Veins

Systemic veins Pulmonary Veins

-Right Pulmonary vein
-Left Pulmonary vein

Head & Neck Abdomen & Thorax Upper limb Lower limb
 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
Internal group
a) Internal jugular
b) External jugular a) Venous sinuses
c) Anterior jugular b) Emissary veins
d) Oblique jugular c) Diploic veins
e) Posterior external jugular
 Superficial Deep

External jugular Facial Pterygoid plexus

Superficial temporal Internal 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 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)
Communications
1. With external jugular by oblique jugular
2. With cavernous sinus by inferior petrosal sinus
 Special characteristics of the blood flow

2
 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
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)
 Anastomosis of facial vein

Facial vein anastomose

with infraorbital vein and
mental vein.

Joins the:
Pterygoid plexus through
deep facial vein
Cavernous sinus through
superior ophthalmic 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 veins
c) 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 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
 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 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.
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  Terminal
 Occipital vein  Transverse cervical
 anterior jugular
 Oblique jugular
 Suprascapular vein
 Posterior external jugular
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. Skin
2. Superficial tissues of neck

Applied anatomy:
3. Special care required to
preserve the vein during
surgical treatment
of wry neck
 Intracranial Venous sinus
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
 Classification

Posterosuperior group Anteroinferior group

Unpaired
a) Superior sagittal Unpaired
b) Inferior sagittal a) Anterior intercavernous
c) Straight b) Posterior intercavernous
d) Occipital c) Basilar

Paired Paired
a) Transverse a) Cavernous
b) Sigmoid b) Superior petrosal
c) Petrosquamous c) Inferior petrosal
d) Sphenoparietal
e) Middle meningeal
 Superior sagittal sinus
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
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
 Inferior sagittal sinus
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
 Straight sinus
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
 Transverse sinus
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)
 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
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 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
 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 sinus
1. Paired sinus, large venous space situated in MCF
2. 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 Structures in
through sinus lateral wall of
sinus

ICA III cranial nerve

VI cranial nerve IV cranial nerve

V 1 and V2 division
of V cranial nerve
 Tributaries

From orbit From brain Meningeal

a) Superior ophthalmic a) Middle cerebral vein a) Middle meningeal

vein b) Inferior cerebral vein vein
b) Inferior ophthalmic b) Sphenoparietal
vein sinus
c) Central vein of retina
Communication with:
a) Transverse sinus d) Facial vein
b) IJV e) Superior sagittal sinus
c) Pterygoid venous plexus f) Opposite cavernous sinus
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
 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 sinus
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
 Inferior petrosal sinus
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
 Middle meningal sinus
Communicate cavernous
sinus with superior sagital
sinus
Unite to form
- parietal
- frontal
Liable to be torn during skull
fracture
 Communication between
intracranial veins &
extracranial veins

Emissary Diploic Ophthalmic Venous

•Mastoid •Frontal •Superior plexus
•Parietal •Anterior opthalmic •Pterygoid
•Condylar temporal •Inferior •Suboccipital
•Occipital •Posterior opthalmic •Pharyngeal
•Sphenoid temporal
•Zuckerkandl’s •Occipital
 Ophthalmic veins
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.
• 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 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
 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:
4. parietal
5. occipital
6. mastoid
7. condylar
8. Spheniod
9. Zuckerkandl’s
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
 Venous plexus
a) PTERYGOID

Location:
Between lateral and
medial pterygoid or
between temporal and
lateral pterygoid
Boundaries:
1. Anterior-maxillary
tuberosity
2. Superior-base of skull

Termination:
• Posteriorly these veins
unite to form deep facial
or maxillary vein
Tributaries:
1. Sphenopalatine
2. Deep temporal
3. Pterygoid
4. Masseteric
5. Buccal
6. Dental
7. Greater palatine
8. Middle meningeal
9. 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 sinus
3. Occipital veins
4. Internal vertebral venous plexus
5. Condylar emmissary veins
3. Drains into vertebral veins
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

 Central venous pressure
Normal
Site pressure range
pressure of blood in the
(in mmHg)
thoracic vena cava, near
the right atrium Central venous pressure 3–8

Right ventricular systolic 15–30

Normal CVP can be measured pressure diastolic 3–8
from two points of reference:
Pulmonary artery systolic 15–30
pressure diastolic 4–12
Sternum: 0–5 cm H2O
Pulmonary vein/
2–15
Midaxillary line: 8-15 cm H2O Pulmonary capillary wedge pressure

Left ventricular systolic 100–140

pressure diastolic 3-12
Factors that Factors that increase CVP
decrease CVP
include: include:

Hypovolemia
Hypervolemia
Deep inhalation forced exhalation
Distributive Tension pneumothorax
shock Heart failure
Pleural effusion
Decreased cardiac output
Cardiac tamponade
Mechanical 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 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.
 Conclusion
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.
 References
1. Textbook of oral anatomy-sicher & dubrul
2. Human Anatomy – B.D. Chaurasia
3. Wikipidia
Thank you