VENOUS SUPPLY OF

HEAD, NECK AND FAC

• BY: Dr. Murtaza contractor MDS I
INTRODUCTION

• The venous system is a network of conduits i.e. veins which transport

deoxygenated blood from tissues to the heart. Exceptions are the
pulmonary and umbilical veins, both of which carry oxygenated blood to
the heart. Equally important ,they serve as major reservoirs of blood.
• About 84% of entire blood volume of body is in systemic circulation and
16% in heart and lungs.
• Of the 84 % in systemic circulation,64%is in veins,13%in arteries and 7%
in systemic arterioles and capillaries
VESSELS OF CIRCULATION

1. Arteries
2. Veins
3. Lymphatics
4. Arterioles
5. Capillaries
EMBRYOLOGY OF VEIN

• The primitive vascular structure in complex capillary and reticular

plexuses in the early embryonic stage is soon replaced by the newly
developed paired cardinal veins as an axial, truncal venous system
• the paired vitelline vessels from the yolk sac develop into the hepatic
portal system, while the paired umbilical vessels from the chorion and
body stalk form the ductus venosus
• The anterior and posterior cardinal veins merge to become the ‘common
cardinal veins,’ draining centrally into the sinus venosus (sinus horns) and
also receiving the ‘vitelline’ and ‘umbilical’ veins
• At 4 weeks, the paired umbilical veins return blood from the placenta to
capillary networks in the liver. During the fifth week of development, the
right umbilical vein degenerates, involutes together with the proximal portion
of the left umbilical veins, leaving only the distal part of the left umbilical
vein as a single vein to return blood from the placenta to the embryo.
FUNCTIONS OF VEIN

• All veins return deoxygenated blood from all the organs to heart
• Exception:
o Pulmonary veins
o Umbilical veins
VEINS- CLASSIFICATION

• Veins are classified as:

1. Superficial veins are those whose course is close to the surface of the body, and have no
corresponding arteries.
2. Deep veins are deeper in the body and have corresponding arteries.
3. Communicating veins (or perforator veins) are veins that directly connect superficial
veins to deep veins.
4. Pulmonary veins are a set of veins that deliver oxygenated blood from the lungs to the
heart.
5. Systemic veins drain the tissues of the body and deliver deoxygenated blood to the heart.
VEINS- WALLS AND VALVES

• 3 layers, similar to artery:

1. Tunica intima
2. Tunica media
3. Tunica externa
• Less smooth muscles and connective tissue compared to artery i.e., thinner walls
• Medium and large veins have venous valves similar to semilunar valve of heart
• Valve in leg and arms are very important to prevent the backflow of blood due to gravity
 Exterior Cervical Cranial and
head & face veins Intracranial
Exterior head & face
Supratrochlear

Supra-orbital

Superficial temporal

Facial

Maxillary

Pterygoid plexus

Retromandibular

Posterior auricular

Occipital
Cervical veins
external jugular

Internal jugular

Anterior jugular

Subclavian

brachiocephalic
Cranial and Intracranial

Diploic

Cerebral

Dural venous sinuses

VEINS OF HEAD AND FACE
SUPRA TROCHLEAR VEIN

• Starts on the forehead from

venous network which connects to
the frontal tributaries of
superficial temporal vein
• Later joins with supra-orbital vein
to form facial vein near medial
canthus
SUPRAORBITAL VEIN

• It begins near zygomatic process of

frontal bone, connecting with radicles of
superficial and middle temporal veins.
• Passes medial above to orbital opening
under orbicularis oculi where it joins
supratrochlear to form facial vein.
• A branch through supra-orbital notch joins
superior ophthalmic vein, receiving veins
from frontal sinus and frontal diploe.
FACIAL VEIN

• Receives supratrochlear and supraorbital

veins
• Descends obliquely near side of radix nasi,
receding from ala
• Turns posterolateral below orbital opening,
passing downwards and backwards behind
facial artery
FACIAL VEIN (CONT.)

• A little antero-inferior to mandibular angle it joins anterior div.

of retromandibular vein.
• Enters internal jugular near greater cornu of hyoid bone
• Its upper most segment, above its junction with superior labial
vein, often termed as the angular vein
TRIBUTARIES (FACIAL VEIN)

• Near beginning, facial vein

connects with superior ophthalmic
directly and via supraorbital,
connected to cavernous sinus.
• Receives veins from ala nasi
TRIBUTARIES OF FACIAL VEIN (CONT.)

• Deep facial vein receives from pterygoid venous plexus and also
inferior palpebral, sup. And inf. Labial, buccinator, parotid and
masseteric veins.
• Below mandible, sub-mental, tonsillar, external
palatine(paratonsillar) and submandibular veins joins facial vein
CLINICAL ANATOMY (FACIAL VEIN)

• No valves
• Connects with cavernous sinus by two routes:
1. Ophthalmic or its supraorbital tributary
2. Deep facial vein to pterygoid plexus
• Infection may thus spread from face to intracranial venous sinuses
SUPERFICIAL TEMPORAL VEIN

• Begins in a widespread network joined across scalp

to contra-lateral vein and with supratrochlear,
supraorbital, posterior auricular and occipital veins,
all draining same network
• cross posterior root of zygoma & enters parotid gland
to unite with maxillary vein to form retromandibular
vein.
MAXILLARY VEIN

• A short trunk accompanies the first part of

maxillary artery;
• It is confluence of vein from pterygoid plexus,
passes back between spheno-mandibular ligament
and neck of mandible, to enter the parotid gland
and
• Here it unites with superficial temporal to form
retromandibular vein.
RETROMANDIBULAR VEIN

• Runs posterior to ramus of the mandible within

the substance of parotid gland
• Superficial to external carotid artery and deep to
facial nerve
• Divides into an anterior division going forwards
to join with facial vein forming common facial
• Posterior division which joins posterior auricular
to form external jugular vein
POSTERIOR AURICULAR VEIN

• Begins upon the side of neck, in a plexus which

communicates with tributaries of occipital vein and
temporal veins.
• Descends behind the auricula and joins the posterior
division of retromandibular vein to form external
jugular vein.
• Applied: receives mastoid emissary veins from sigmoid
sinus. Infection here can be dangerous or fatal from
retrograde thrombosis of cerebellar and medullary veins
OCCIPITAL VEIN

• Begins in posterior network in scalp, pierce the cranial

attachment of trapezius, turns into suboccipital triangle
and becomes deep.
• May follow occipital artery to end in internal jugular
vein;
• Or join posterior auricular & hence external jugular
vein.
PTERYGOID VENOUS PLEXUS

• Placed partly between temporalis and lateral pterygoid and partly between
two pterygoids.
• Anteriorly reaches from the maxillary tuberosity and superiorly to the base
of skull
• Sphenopalatine, deep temporal, pterygoid, masseteric, buccal, dental,
greater palatine and middle meningeal veins and branches from inferior
ophthalmic veins are all tributaries.
• Connects with facial veins facial veins through deep facial veins &
PTERYGOID VENOUS PLEXUS (CONT.)

• With cavernous sinus through veins that pass through sphenoidal emissary
foramen, foramen ovale and lacerum
• Its deep tributaries are connected with middle meningeal vein.
APPLIED ANATOMY OF
PTERYGOID VENUS PLEXUS

• Applied : needle track

communications can also result
in infection to pterygoid plexus.
• PSA Block hematoma, black eye
• serves as a media for spread of
external infection to eye.
PATHWAY OF SPREAD OF INFECTION TO CAVERNOUS
SINUS
CERVICAL VEINS
VEINS OF NECK

• The word "jugular" refers to the

throat or neck. It derives from the
Latin "jugulum" meaning throat or
collarbone and the Latin "jugum"
meaning yoke. To go for the jugular
is to attack a vital part that is
particularly vulnerable.
EXTERNAL JUGULAR VEIN

• largely drains scalp and face, but also some deeper

parts.
• Formed by union of post division of
retromandibular vein & post auricular vein.
• Begins near the angle of mandible, just below the
parotid gland and drains into subclavian vein.
• Covered with platysma and superficial fascia and
separated from sternocleidomastoid by deep
cervical fascia.
EXT. JUGULAR VEIN (CONT.)

• Between the entrance into subclavian vein, about 4cm above clavicle, it is
often dilated as so called sinus.
• Surface anatomy: usually visible as it crosses sternocleidomastoid
obliquely. Can be seen by effort blowing of mouth closed
TRIBUTARIES OF EJV

• Posterior external jugular vein

• Transverse cervical vein
• Suprascapular vein
• Anterior jugular vein
• A branch from internal jugular in the parotid
• Occasionally joined by occipital
DIFFERENTIATION FROM THE CAROTID PULSE

• Jugular venous pulse and carotid pulse can be differentiated several ways
• Multiphasic – JVP beats twice in quick succession in cardiac cycle. First beat
is for atrial contraction and second for venous filling. Carotid artery only has
one beat in the cardiac cycle
• Non-palpable – JVP cannot be palpated. If one feels a pulse in neck, it is
generally the common carotid artery.
• Varies with head-up-tilt(HUT) – the JVP varies with angle of neck. If a
person is standing his JV appears to be lower on the neck. The carotid pulse
location does not vary with HUT
ANTERIOR JUGULAR VEIN

• Starts near the hyoid bone by confluence of superficial

submandibular vein.
• Descends between midline and ant border of Sternocleidomastoid
turning laterally, low in neck, posterior to this muscle but
superficial to depressor of hyoid bone
• Joins external jugular vein or subclavian vein directly.
• There are usually two anterior jugular veins, just above the
sternum, communicate by large transverse trunk, the venous
jugular arch
• has no valves
INTERNAL JUGULAR VEIN

• Begins at the base of the skull in the

posterior compartment of jugular foramen
• collects blood from brain
• Immediately below the jugular foramen, it is
widened to form superior bulb of internal
jugular v, contained in jugular fossa
IJV (CONT.)

• Located post. to internal carotid artery

• At its lower end, at the junction with subclavian vein v , IJV is again
widened to form inferior bulb
• Posterior to sternal end of clavicle, IJV combines with subclavian vein to
form brachiocephalic vein .
SURFACE & APPLIED ANATOMY (IJV)

• Surface anatomy :IJV is represented in surface projection by

broad band drawn from lobule of ear to median end of clavicle.
• Applied: infection from middle ear spreads to IJV
• Surgical removal of deep cervical nodes can puncture IJV
CANNULATION OF IJV

• Why we do cannulation?
• Seldinger technique
• IJV often chosen for cannulation because of several advantages:
1. Superficial location
2. Easy ultrasonic visualization
3. Straight course to superior vena cava (right)
4. IJV avoids subclavian “pinch-off syndrome”
DEEP CERVICAL LYMPH NODES

• are found along the internal jugular vein within the carotid sheath.
• In block dissection, the the subclavian vein, JV is removed to facilitate the
removal of nodes.
• In the root of neck, IJV lies behind the gap between sternal and clavicular
heads of SCM and ends by joining the subclavian vein to form
brachiocephalic vein.
• Pharyngeal vein, Common facial vein & superior and middle thyroid veins
also drain into IJV.
DEEP CERVICAL LYMPH NODES (CONT.)

• Undue traction during thyroid surgery can result in avulsion of these veins
from IJV.
• Gentle traction , double ligation of these veins are important steps in
mobilization of thyroid lobes
• Bilateral internal external, posterior external and anterior jugular vein
ligations and excisions performed in the neck due to larynx tumors .
• Radical neck dissection is a standard procedure in the management of head
and neck cancer patients with bilateral lymph node metastasis to the neck.
DEEP CERVICAL LYMPH NODES (CONT.)

• Sacrifice of both internal and external jugular veins bilaterally has been
recognized as a dangerous approach leading to intracranial hypertension
with subsequent neurological sequela and death.
• After bilateral jugular vein ligations, digital subtraction angiography
(DSA) showed that the venous drainage route of the brain had been
diverted from the jugular veins to the vertebral venous plexus.
TRIBUTARIES OF IJV

• Into superior bulb

• Inferior petrosal sinus
• Veins of pharynx
• Root of tongue & sublingual area
• Superior thyroid vein
• Middle thyroid vein
TRIBUTARIES OF IJV (CONT.)

• At the root of the neck, the right internal jugular vein is a little distance
from the common carotid artery, and crosses the first part of the
subclavian artery, while the left internal jugular vein usually overlaps the
common carotid artery.
• The left vein is generally smaller than the right, and each contains a pair
of valves, which are placed about 2.5 cm above the termination of the
vessel.
APPLIED ASPECTS IJV

• Thrombosis of the internal jugular (IJ) vein is an underdiagnosed condition that

may occur as a complication of head and neck infections, surgery, central
venous access, local malignancy, polycythaemia, hyperhomocysteinemia, neck
massage, and intravenous drug abuse.
• thrombosis may become secondarily infected, producing a septic
thrombophlebitis. An infected IJ thrombus caused by extension of an
oropharyngeal infection is referred to as Lemierre syndrome. The incidence of
Lemierre syndrome has fallen dramatically since the use of antibiotics began in
the late 1950s. However, it still occurs, particularly in underserved populations.
APPLIED ASPECTS IJV (CONT.)

• The jugular veins are relatively superficial and not protected by tissues such
as bone or cartilage. This makes them susceptible to damage. Due to the
large volumes of blood that flow though the jugular veins, damage to the
jugulars can quickly cause significant blood loss, which can lead to
hypovolemic shock and then death if not treated
• It should also be noted that cuts or abrasions in the skin near the jugular vein
will bleed longer and more profusely (i.e. from chewing tobacco or shaving
accidents). Since 95% of the body's blood passes through this vein, it takes
on average about 30 minutes to fully stop a shaving abrasion on the face.
LINGUAL VEIN

• Drains tongue and sublingual region

• 3 branches :
1. Dorsal lingual
2. Deep lingual
3. Sub lingual
LINGUAL VARICOSITY

• Abnormally 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”
• Veins are supposed to act as one-way valves and shouldn't allow back flow of
blood. But if a vein becomes weak, blood may flow backwards and collect in
vein causing inflammation and swelling. These swollen veins are varicose veins.
• Varicose veins are normally found on the backs of your calves or on the inside
of your leg.
VARIATIONS OF SUPERFICIAL CERVICAL VEINS

• Imp and frequent variations are as follows:

1. Common facial vein absent. Retromandibular vein continues into EJV.
Facial vein into IJV
2. Retromandibular vein opens into IJV facial vein into AJV. Common
facial vein absent
3. Common facial vein empties into EJV
4. Retromandibular vein continues into EJV, facial vein into AJV
CRANIAL AND INTRA-CRANIAL VEINS
DIPLOIC VEINS

• These veins occupy channels in diploe of some cranial bones and are
devoid of valves.
• They are large with dilation at regular interval; their thin wall is merely
endothelium. Absent at birth, begin to develop at about 2yrs.
• They communicate with meningeal veins, Dural sinuses & peri cranial
veins.
• Four diploic veins:
1. Frontal diploic vein
2. An ant. Temporal diploic vein
3. A post. Temporal diploic vein
4. An occipital vein
CEREBRAL VEINS

• They are divided into external &

internal groups according to the
outer surface or inner parts of
hemispheres the
• External cerebral veins drain into
superior sagittal sinus
• Internal cerebral veins drain into
great cerebral veins of Galen
SINUSES OF DURA MATTER
CRANIAL VENOUS SINUSES

• These are spaces between endosteal & meningeal layers of dura mater.
 General features:
• Their walls are formed by dura mater lined by epithelium, muscular coat is
absent
• They have no valves
• Receive: 1. venous drain from brain, meninges and bone
2. the CSF
DURAL VENOUS SINUSES

Paired Unpaired

Cavernous sinus Superior sagittal sinus

Superior petrosal sinus Inferior sagittal sinus

Inferior petrosal sinus Straight sinus

Transverse sinus Occipital sinus

Sigmoid sinus Ant. Intercavernous S

Sphenoparietal sinus Post. Intercavernous S

Middle meningeal veins Basilar plexus of veins

CLINICAL RELEVANCE

• 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
• Most common thrombosed sinuses are transverse, cavernous & superior
sagittal sinus
METASTASIS OF TUMOUR CELLS TO DURAL
SINUSES
• The basilar and occipital sinuses communicate through the foramen
magnum with the internal venous plexuses
• Because these venous channels are valve less, 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 result, pus in the abscesses and tumour cells in these regions may
spread to vertebrae and brain.
CAVERNOUS SINUS

• so named because they present a

reticulated structure, due to their
being traversed by numerous
interlacing filaments
• situated in the middle cranial fossa,
one on either side of sphenoid bone
• Dimentions: 2cms long, 1cm wide
EXTENDS OF CAVERNOUS SINUS

• Anterior – superior orbital fissure.

• Posterior – petrous part of the temporal bone.
• Medial – body of the sphenoid bone.
• Lateral – meningeal layer of the dura mater
running from the roof to the floor of the middle
cranial fossa.
• Roof – meningeal layer of the dura mater that
attaches to the anterior and middle clinoid
processes of the sphenoid bone.
• Floor – endosteal layer of dura mater that overlies
the base of the greater wing of the sphenoid bone.
CONTENTS OF CAVERNOUS SINUS

Travels through cavernous Travels through lateral wall of

sinus: cavernous sinus:
Abducens nerve (CN VI) Oculomotor nerve (CN III)

Carotid plexus (post-ganglionic Trochlear nerve (CN IV)

sympathetic nerve fibres)

Internal carotid artery (cavernous Ophthalmic (V1) and maxillary (V2)

portion) branches of the trigeminal nerve
DRAINAGE CAVERNOUS SINUS

1. Transverse sinus via superior petrosal sinus

2. Internal jugular vein via inferior petrosal sinus & venous plexus around
internal carotid artery
3. Pterygoid plexus through emissary veins passing through foramen ovale
4. Facial vein through superior ophthalmic vein
• Right and left communicate with each other through intercavernous sinus and
basilar plexus of veins
• All these communications are valveless and blood can flow in either
direction
APPLIED ANATOMY (CAVERNOUS SINUS)

Thrombosis caused by sepsis in the danger area of face, nasal cavity, paranasal
sinuses give rise to :
• Nervous symptoms:
1. Severe pain in eye and forehead in the area of distributed of ophthalmic nerve.
2. Involvement of 3rd, 4th and 6th nerve resulting in paralysis of muscle supplied.
• Venous symptoms:
1. Marked edema of eyelid, cornea & exophthalmos due to congestion of orbital
vein
APPLIED ANATOMY (CONT.)

• 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 exophthalmos)
REFERENCES

1. Oral anatomy by Sicher and Dubrul

2. Gray’s Anatomy
3. Langman J. Medical Embryology. 5th ed. Baltimore, MD: Williams and
Wilkins;1985:212–217.
4. Warwick R, Williams P. Gray’s Anatomy. 37th ed. Edinburgh, London, Melbourne, New
York: Churchill Livingstone;1989:326-327.
5. Hamilton WJ, Mossman HW. Hamilton, Boyd & Mossman’s Human Embryology. 4th ed.
Cambridge: Heffer;1972:261.
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