CASE REPORT |
https://doi.org/10.5005/jp-journals-11003-0149 |
Unilateral Anomalous Venous Pattern of Face and Neck—Clinico-embryological Perspective: A Case Report
1–4Department of Anatomy, Amrita Vishwa Vidyapeetham, Amrita School of Medicine, Faridabad, Haryana, India
Corresponding Author: Vandana Dave, Department of Anatomy, Amrita Vishwa Vidyapeetham, Amrita School of Medicine, Faridabad, Haryana, India, Phone: +91 9350744442, e-mail: daveveenu@gmail.com
Received: 24 September 2024; Accepted: 22 October 2024; Published on: 31 December 2024
ABSTRACT
During a routine dissection class of undergraduate medical students, unilateral variations of the major superficial veins of the face and neck were observed in an adult male Indian cadaver.
The standard anatomical description of the external jugular vein (EJV) consists of the posterior auricular vein joining the posterior division of the retromandibular vein (RMV). The variations were observed on the left side of the face. The RMV exhibited normal formation but was not divided into anterior and posterior divisions. The EJV was formed by the union of the facial vein and the undivided RMV. The posterior auricular vein was also absent. The EJV bifurcated into two branches, which terminated into the cephalic vein. The veins on the right side displayed normal anatomy. The RMV is an important anatomical structure in radiology practice that can be used to localize a tumor in the parotid gland and is also used as a guide to expose the facial nerve branches in superficial parotidectomy and in open reduction of mandibular condylar fractures. The present paper reports a variation in the superficial veins of the face and neck and is an attempt to reinforce awareness of such variations among clinicians and plastic surgeons in view of reconstructive procedures.
Keywords: Case report, Cephalic vein, External jugular vein, Posterior auricular vein, Retromandibular vein
How to cite this article: Dave V, Dhankar R, Agarwal M, et al. Unilateral Anomalous Venous Pattern of Face and Neck—Clinico-embryological Perspective: A Case Report. J Med Acad 2024;7(2):74–76.
Source of support: Nil
Conflict of interest: None
Patient consent statement: The author(s) have obtained written informed consent from the patient for publication of the case report details and related images.
INTRODUCTION
Venous anomalies of the face and neck are common. These variations are important while performing catheterization by surgeons and radiologists. Awareness of the variations in the veins of the head and neck is essential for minimizing the risk during the management of mandibular fractures, parotid, and oral reconstruction surgeries. The tributaries of the retromandibular vein (RMV) are usually ligated to prevent bleeding during surgery.1 The external jugular vein (EJV) serves as a crucial pathway for placing venous access devices and can act as an alternative to the cephalic vein.2
The RMV is formed by the junction of the maxillary and superficial temporal veins within the parotid gland. After a short course, it typically divides into anterior and posterior branches. The anterior branch merges with the facial vein to form the common facial vein, while the posterior branch joins the posterior auricular vein to form the EJV.3 The veins of the head and neck originate from the first and second pharyngeal arches, with development beginning during the 5 mm embryonic stage. These veins drain into the common cardinal vein via a venous channel called the ventral pharyngeal vein. The internal jugular vein is formed as the ventral pharyngeal vein shifts upward during neck elongation. In the 18 mm embryonic stage, the ventral pharyngeal vein gives rise to the linguofacial vein and receives RMV. The EJV is derived from the cranial portion of the ring formed by the cephalic vein around the clavicle. As development progresses, the primitive maxillary vein connects with the linguofacial vein to form the facial vein. At the 40 mm embryonic stage, the EJV establishes a cranial connection with the RMV and facial vein. The anterior connection to the facial vein usually regresses after birth, leaving the facial vein connected solely to the internal jugular vein.3 However, variations in the development, course, tributaries, and termination of RMV, EJV, and superficial veins of the face have been reported in the literature.4,6
The EJV is commonly used for cannulation in intravenous therapies and diagnostic procedures due to its superficial location and reliable estimate of central venous pressure.7 It is also utilized in permanent catheterization for hemodialysis, a relatively straightforward procedure with minimal complications.8 Variations in venous drainage patterns are particularly relevant for head and neck surgeries involving microvascular anastomosis.
CASE DESCRIPTION
During routine dissection of an Indian male cadaver, a variation in the superficial veins of the face and neck was observed.
Detailed dissection revealed that the RMV formed normally by the union of the superficial temporal vein and the maxillary vein, but did not bifurcate into anterior and posterior divisions. Additionally, the posterior auricular vein was absent. Instead, the RMV descended and joined the facial vein 4.2 cm below the mandibular angle, forming the EJV. The EJV then coursed downward for 9.7 cm before bifurcating into two branches of 3.1 cm. These branches passed superficial to the clavicle and drained into the cephalic vein 1.5 cm below the clavicle, with a 0.6 cm distance between their points of termination.
A significant communication was observed between the internal jugular vein and RMV, which passed superficially to the external carotid artery and then passed deep to the artery close to the point of origin of the posterior auricular artery. Eventually, it joined the RMV (Fig. 1).
Fig. 1 Dissection of face and neck (left side) showing anomalous RMV and EJV. #, tributaries of IJV; *, posterior auricular artery; AC, ansa cervicalis; C, clavicle; CV, cephalic vein; EJV, bifurcating external jugular vein; FV, facial vein; IJV, internal jugular vein; RMV, retromandibular vein; XII, hypoglossal nerve
DISCUSSION
The superficial veins of the face and neck develop from a capillary plexus that evolves as the fetal skull forms. Larger venous channels emerge through capillary enlargement, confluence, and regression of certain veins.9,10 Variations in the venous pattern of this region are common.11
The ventral pharyngeal vein is the first identifiable vessel, which drains the mandibular and hyoid arches into the cranial portion of the precardinal vein.12 This vein later receives tributaries from the face and tongue, forming the linguofacial vein. The linguofacial vein then forms anastomoses with the primitive maxillary vein, creating the facial vein, which subsequently receives the RMV. The EJV is formed by the cranial part of a venous ring formed by the cephalic vein around the clavicle. In the current case, the termination of the EJV into the cephalic vein may be explained by the persistence of an embryological connection. Normally, during development, the primitive maxillary vein merges with the linguofacial vein to form the facial vein. In the 40 mm embryonic stage, the EJV establishes cranial connections with the RMV and facial vein.3 Persistence of these embryonic connections after birth can result in anomalies, such as the one observed in this case.
The case presented here describes a unilateral variation in the formation and termination of the EJV and RMV. Similar variations have been documented previously. For instance, Sanyal and Joeaneke13 reported a right-sided undivided RMV that continued as the EJV and drained into the subclavian vein, while the facial vein drained into the internal jugular vein. Other studies, such as those by Ankolekar et al.,14 have described variations in the formation of RMV, which is formed by the union of the superficial temporal vein and facial vein buried in the parotid gland. The anterior division of RMV joined the submental vein to form an anomalous venous channel, which drained into the EJV. The common facial vein, which is draining into the EJV, could be explained by a persistent anastomotic channel between the secondarily developing EJV and the primitive linguofacial vein.15
The EJV is known to exhibit significant variability, particularly at its origin. These variations include the formation of the EJV simply by the posterior auricular vein or receiving tributaries like the lingual, facial, or cephalic veins, or coursing over the clavicle and draining into the subclavian, cephalic, or internal jugular veins. Doubling of the EJV has also been reported. An annulus formation has also been observed around the clavicle.16
Yadav et al.17 described a case where the EJV drained into the internal jugular vein, receiving tributaries from the posterior jugular vein. However, in our study, the EJV drained into the cephalic vein, and no posterior auricular vein was observed. Additionally, a tributary from the internal jugular vein communicated with the RMV, passing deep to the parotid gland. However, our observation is at slight variance from the standard description, in which the communication exists within the parotid gland.
Variations in the cephalic vein are also well documented, including its potential absence or reduction in size. An accessory cephalic vein may sometimes accompany it.16 Poirier and Charpy18 noted that the cephalic vein can connect to the EJV via a connecting branch anterior to the clavicle, a finding consistent with the present case. Le Saout et al.19 identified similar cases involving connections between the cephalic vein and collateral branches of the external jugular.
In this study, the EJV exhibited a unique bifurcation into two branches, which independently drained into the cephalic vein, which has not been reported previously in the literature.
The significance of these venous variations lies in their implications for surgical procedures, such as carotid endarterectomy or reconstructive surgeries of the oral cavity.20 These veins are often utilized in microvascular anastomosis. The EJV is increasingly employed in diagnostic procedures and intravenous therapies.21 The preoperative evaluation of their course and branching patterns is essential to minimize complications, as this helps the surgeons in planning surgery.
CONCLUSION
The uniqueness of this report lies in the fact that we report the coexistence of an undivided RMV, absence of the posterior auricular vein, and variant bifurcate drainage of the EJV into the cephalic vein. Comprehensive anatomical knowledge is critical for the success of microvascular surgical procedures and to avoid potential complications.
ORCID
Vandana Dave https://orcid.org/0009-0008-1011-0381
Ruchika Dhankar https://orcid.org/0009-0002-3173-195X
Meetu Agarwal https://orcid.org/0000-0002-9470-4943
Sushil Kumar https://orcid.org/0000-0001-7776-5878
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