GITAM DENTAL COLLEGE & HOSPITAL

DEPARTMENT OF
ORAL & MAXILLOFACIAL SURGERY

SEMINAR ON
Venous drainae o! "ead & ne#$ reion & s%read o! in!e#&ion &"rou"
'enous drainae


Presented By:
Dr. Sambhav K Vora

I MDS
Contents
1. Introduction
2. Classification of veins
3. Veins of head & neck
4. Veins of scalp & face
5. Variations in the superficial cervical veins
6. Sinuses of the duramater
. !missar" veins
#. $iploic veins
%. Spread of infection throu&h the venous draina&e
1'.Cavernous sinus throm(osis.

)im* +o stud" the course & position of the veins of the head & neck & its
protection ,hile performin& sur&eries related to that area.
+he venous (lood of head &neck is drained almost entirel" (" the internal
-u&ular vein. ,hich -oins the su(clavian vein. (ehind the sternoclavicular
articulation to form the (rachiocephalic vein. +he t,o (rachiocephalic vein
unites to form the superior vena cava. )lon& the neck .t,o superficial veins
are added to the deep internal -u&ular vein namel" the e/ternal & anterior
-u&ular vein.
C0)SSI1IC)+I23 21 V!I3S4
Veins of e/terior of head &neck
Cervical veins
$iploic. menin&eal. &dural venous sinuses
V!I3S 21 +5! 3!C6
Veins of the neck are superficial and deep to the deep fascia. Superficial
veins are anterior -u&ular. e/ternal -u&ular and posterior -u&ular veins4 the"
drain a smaller part of tissue than deep veins. $eep veins drain all
su(cutaneous structures mostl" internal -u&ular veins and into the su(clavian
vein. Superficial veins
$eep veins

V!I3S 21 5!)$ &3!C6
Vein +ermination +ri(utaries )reas drained
Su%er!i#ia(
'eins
1.facial
Common facial
vein
1.supratrochlear
2.supraor(ital
3.nasal
4.superior la(ial
5.inferior la(ial
6.muscular
.su(mental
#.tonsillar
%.
Su(mandi(ular.
Scalp. forehead
.upper e"elid
Scalp.forehead.uppe
r e"elid
!/ternal nose
7pper lip
0o,er lip
8asseter &
(uccinator muscle
Su( mental structure
9alatine
tonsil&tonsillar (ed
Su(mandi(ular
&land
2.superficial :etromandi(ula 1.scalp )nterior & posterior
temporal r
2.&landular
3.auricular
4.articular
5.transverse
facial
re&ion of scalp
9arotid &land
!/ternal ear
+emporomandi(ular
-oint
Side of the face
&cheek.
3.pter"&oid
ple/us of veins
8a/illar" veins
&small
contri(ution to
cavernous sinus
1.infraor(ital
2.sphenopalatine
3.muscular
4.(uccal
5.palatine
a. &reater
palatine
(. lesser
palatine
6.inferior
alveolar
a. mental
. deep facial
0o,er e"elid.
e/ternal nose. upper
lip . ma/illar" teeth
3asal cavit".
anterior end of hard
palate
8uscles of
mastication
Cheek & (uccal
mandi(ular &in&ivae
9osterior t,o thirds
of the hard palate
Soft palate
8andi(ular teeth
0o,er lip. chin.
mandi(ular la(ial
&in&ivae
) direct
communication ,ith
the facial
4.ma/illar" :etromandi(ula
r
9ter"&oid ple/us See a(ove
:etromandi(ula
r
)nterior &
posterior
divisions
1.superficial
temporal
2.ma/illar"
See a(ove
Common facial Internal -u&ular 1.facial
2.retromandi(ula
r
;anterior
division<
See a(ove
!/ternal -u&ular Su(clavian 1.retromandi(ula
r ;posterior
See a(ove
division<
2.posterior
auricular
3.transverse
cervical
4.suprascapular
5.anterior -u&ular
Scalp posterior to
ear. e/ternal ear
3eck
3eck &upper (ack
Structures of the
anterior trian&le of
the neck.
I3+!:3)0 =7>70): V!I3*
+he internal -u&ular vein receives (lood from the (rain. face. &neck. It
commences at the -u&ular foramen in the skull as the continuation of the
si&moid sinus it descends throu&h the neck in the carotid sheath &unites
,ith the su(clavian vein (ehind the medial end of the clavicle to form the
(rachiocephalic vein. immediatel" (elo, the -u&ular foramen the vein is
,idened to form the superior (ul( of the internal -u&ular vein ,hich is
contained in the -u&ular fossa on the inferior surface of the temporal (one.
:elations*
)nterolaterall" ?skin. fascia. sternocleidomastoid. &the parotid salivar"
&land
0o,er end is covered (" the sternoth"roid. sternoh"oid. & omoh"oid
muscles
5i&her up is crossed (" st"loh"oid. posterior (ell" of the di&astric &the
spinal accessor" nerve
9osteriorl"@transverse process of cervical verte(rae. levator
scapulae.scalenus medius.scalenus anterior .cervical ple/us.phrenic
nerve.th"rocervical trunk. verte(ral vein.& the first part of su(clavian arter"
8ediall" ?a(ove lies the internal carotid arter"& the ninth. eleventh.
&t,elfth cranial nerves. Aelo, lies the common carotid arter" & the va&us
nerve.
+ri(utaries@
Into the superior (ul( opens the inferior petrosal sinus.
Veins of the phar"n/ ton&ue. &su(lin&ual area drain upper part of the
internal -u&ular vein.
)nastomosis (et,een internal &e/ternal -u&ular vein is seen near the upper
corner of the carotid trian&le..
1acial vein alon& ,ith anterior division of the :etromandi(ular vein -oins
the internal -u&ular vein.
Veins of the lar"n/ & th"roid &lands are main tri(utaries at the lo,er part
of the neck.
Linua( 'eins@it drains the ton&ue & su(lin&ual re&ion. It has 3 divisionBs
namel" dorsal veins. deep veins & su(lin&ual vein. +he lar&est of these
veins is the su(lin&ual vein. ,hich accompanies the h"po&lossal nerve .vein
of the ton&ue ma" -oin sin&le lar&e trunk or ma" empt" separatel" into the
internal -u&ular vein
Surface markin&* it is alon& a line from the lo(ule of the ear to the sternal
end of the clavicle. (et,een the t,o heads of the sternocleidomastoid. .In the
neck the internal -u&ular vein lies lateral to the common carotid arter". in
front of the scalenus anterior. .+he -u&ular venous pulse is a &uide to the
-u&ular venous pressure. Cith the patients reclinin& at 45 de&rees the -u&ular
venous pulse should (e visi(le -ust a(ove the clavicle.
)nsa cervicalis lies in the front of the internal -u&ular vein & &ives (ranches
to the infra h"oid muscles.
CatheteriDation* the ri&ht internal -u&ular vein can (e cannulated for the
insertion of the central venous line. for measurements of central venous
pressure. or the rapid administration of the dru&s ,hen the peripheral
approach ,ould (e too slo,. +he vein is usuall" approached throu&h the
centre of the trian&le formed (" the t,o heads of the sternocleidomastoid
&clavicle. +he needle is directed caudall" .parallel to the sa&ittal plane at a
3' de&ree posterior an&le ,ith the coronal plane. enterin& the vein in a(out
4 @5 cm.
Complications@hematoma formation. common carotid arter" puncture.
va&us nerve in-ur". & pneumothora/ due to pleural perforation.
9ulsations of the I=V caused (" contraction of the ri&ht ventricle of the heart
ma" (e palpa(le superior to the medial end of the clavicle. +he pulsations
usuall" are visi(le ,hen the personBs head is 1' to 25 lo,er than the feet.
Aecause there are no valves in the (rachiocephalic vein or superior vena
cava. a ,ave of contraction passes up these vessels to the I=V. +he presence
of valves in the I=V and su(clavian vein. near their respective -unctions
prevents (ackflo, durin& heart contractions
I3+!:3)0 =7>70): V!I3 973C+7:!
) needle and catheter ma" (e inserted into the I=V for dia&nostic or
therapeutic purposes. $urin& this procedure. the clinician palpates the
common carotid arter" and inserts the needle into the I=V -ust lateral to it at
a 3' an&le. aimin& at the ape/ of the trian&le (et,een the sternal and
clavicular heads of the SC8. +he needle is then directed inferolaterall"
to,ard the ipsilateral nipple.
!E+!:3)0 =7>70): V!I3
It drains mainl" scalp and face. .it is formed (" the union of posterior
division of the retromandi(ular vein ,ith the posterior auricular vein and
(e&ins near the an&le of the mandi(le -ust (elo, or in the parotid &land.
1rom here it descends o(liFuel" superficial to the sternocleidomastoid to the
root of the neck and then it crosses the deep fascia and ends in the
su(clavian vein. )lthou&h valves are present in the e/ternal -u&ular vein (ut
it doesnBt prevent re&ur&itation. It is covered (" the plat"sma. superficial
fascia and the skin.

+ri(utaries ? it receives the posterior e/ternal -u&ular vein and transverse.
cervical . suprascapular and anterior -u&ular vein near it s end. It is also
-oined (" the (ranch from the internal -u&ular vein near the parotid &land.
9:28I3!3C! 21 !E+!:3)0 =7>70): V!I3
Chen venous pressure is ,ithin the normal ran&e. the (lood distendin& the
!=V is either not apparent or o(serva(le for onl" a short distance at the (ase
of the neck. 5o,ever. ,hen the pressure rises ? as durin& heart failure for
e/ample ? the !=V (ecomes prominent throu&hout its course alon& the side
of the neck. ConseFuentl". routine o(servation for distention of the !=V
durin& ph"sical e/aminations ma" reveal dia&nostic si&ns of heart failure.
o(struction of the superior vena cava ;e.&. (" tumour cells<. enlar&ed
supraclavicular l"mph nodes. or increased intrathoracic pressure
S7AC0)VI)3 V!I3 973C+7:!
+he ri&ht su(clavian vein often is the point of entr" to the venous s"stem for
central line placement. +his techniFue is used to administer parenteral fluids
;nutritional fluid not introduced via the di&estive s"stem< and medications
and to measure the central venous pressure. +he pleura andGor the
su(clavian arter" are in dan&er of puncture durin& this procedure.
92S+!:I2: !E+!:3)0 =7>70): V!I3
It (e&ins in the occipital scalp and drains into the skin and the superficial
muscles in the postero superior re&ion of the neck. It -oins the middle part of
the e/ternal -u&ular vein.
)3+!:I2: =7>70): V!I3
It arises near the h"oid (one and descends (et,een the midline and the
anterior (order of the sternocleidomastoid. $eep to the sternocleidomastoid
it -oins the e/ternal -u&ular vein or ma" enter su(clavian vein directl". +here
are usuall" t,o anterior -u&ular veins ,hich are united -ust a(ove the
manu(rium (" lar&e transverse )uu(ar ar#" ,hich receives the inferior
th"roid tri(utaries.
1)CI)0 V!I3*@it is the main vein of the face. It travels o(liFuel"
do,n,ards (" the side of the nose &descends to the anterior (order & then
passes over the surface of the masseter. It crosses (od" of the mandi(le
&runs in the neck to drain into the internal -u&ular vein. +he common facial
vein ori&inates (elo, the an&le of the mandi(le from the -unction of the
facial &retromandi(ular vein. a(ove its -unction ,ith the superior la(ial vein
it is termed as an&ular vein. +he an&ular vein receives the frontal vein.
supraor(ital vein. veins from the lo,er lid &from the (rid&e of the nose.
Supraor(ital vein (e&ins
near the D"&omatic process of the frontal (one. passes mediall" piercin& the
or(icularis oculi&unites ,ith the supratrochlear vein .frontal &supra or(ital
veins anastomoses throu&h ,ide venous nets ,ith the other veins of the
scalp. Superficial temporal. posterior auricular &occipital veins. +he an&ular
vein is constantl" in communication ,ith the superior ophthalmic vein -us
a(ove the medial palpe(ral li&ament.& as superior ophthalmic vein opens
into the cavernous sinus a link (et,een facial vein & intracranial sinuses of
the duramater is seen
1acial vein lacks valves & (ecause of its connection ,ith the cavernous
sinus it has the clinical si&nificance in the spread of infection.
su%er!i#ia( &e*%ora( 'ein*
it (e&ins from the ,ide spread ple/us of veins on side of the scalp
&alon& D"&omatic arch.frontal & parietal tri(utaries unite anterior to the
auricle. crosses temporal root of D"&omatic arch to pass from the temporal
re&ion & enter the su(stance of the parotid &land.it -oins ma/illar" vein
posterior to the neck of the mandi(le to form the retromandi(ular vein.
Re&ro*andi+u(ar 'ein,

It is formed (" the union of the superficial temporal & ma/illar" vein in the
su(stance of the parotid &land (ehind the neck of the mandi(le.the vein
emer&es at the lo,er pole of the &land to unite ,ith the facial vein.it
continues do,n,ards on the outer surface of the st"loh"oid &di&astric
muscles In some cases ho,ever the a deep (ranch of
retromandi(ular vein follo,s the e/ternal carotid arter" in its deep course
&empties into the internal -u&ular vein.
)(ove the root of D"&omatic arch .a *idd(e &e*%ora( 'ein opens into the
superficial temporal vein. +his middle temporal vein drains into the venous
ple/us situated underneath the temporal fascia
+he t,o ma/illar" veins are the outlet of the lar&e &dense pter"&oid venous
ple/us ,hich surrouds the ma/illar" arter" in the infra temporal fossa.
P&er-oid %(e.us o! 'eins,
Veins of the deep structures of the face open here. It is situated (et,een
the temporal &lateral pter"&oid or (et,een the lateral &medial pter"&oid
muscles dependin& on the course of the ma/illar" arter"..anteriorl" it
reaches the tu(erosit" of the ma/illa .superiorl" to the (ase of the skull.
+ri(utaries@veins of the masticator" muscles.sphenopalatine veins .drainin&
posterior part of the nasal cavit" &&reater part of the palate . middle
menin&eal veins drainin& the duramater . articular veins from rich ple/us in
&around the capsule of the mandi(ular -oint.auricular veins from the
e/ternal ear. transverse facial vein drainin& the posterior part of the cheek &
the parotid &land.
+he dense venous ple/us surroundin& the ma/illar" arter" serves to protect
the arter" from the compression,hen the masticator" muscles contract.
$urin& their contraction the (ul&in& muscles drive (lood from the veins
&durin& rela/ation the veins fill a&ain.this t"pe of mechanical protective
functions of veins is ver" rare & is seen in the venous ple/us surroundin&
the internal carotid arter" in the carotid canal.
Variations in the superficial cervical veins
+he most important and freFuent variations are*@
1. the common facial vein does not e/ist. +he retromandi(ualr vein
continues into the e/ternal -u&ular vein. the facial vein opens into the
internal -u&ular r vein.
2. the retromandi(ular vein opens into the internal -u&ular vein. the
facial vein continues intot the anterior -u&ular vein. and a common
facial vein a&ain is a(sent.
3. the common facial vein loses its connection ,ith the internal -u&ular
vein and empties instead into the e/ternal -u&ular vein.;choudhar" et
al <
4. retromandi(ular vein continues into the e/ternal -u&ular vein. facial
vein continues into the anterior -u&ular vein.
5. In one of the cadavers the follo,in& variation ,as o(served. the facial
vein ,as found runnin& do,n,ard & (ack,ards at the anterior (order
of masseter.,here the su(mental vein united ,ith the facial vein to
form a common venous channel.the common venous channel united
,ith the retromandi(ular vein at the an&le of the mandi(le to form the
common facial vein. Aefore this common facial vein -oins the internal
-u&ular vein . a venous channel ori&inatin& from the anterior -u&ular
vein comes & -oins the common facial vein &,hich then -oins the
internal -u&ular vein.; - anat.soc.india.52;1<.64@65 ;2''3<<
6. ) case of facial vein unitin& ,ith the superficial temporal vein 5 mm
cranial to the undivided part of retromandi(ular vein has (een
reported (" 9euker et al ;2''1<
V!I3S 21 +5! SC)09 & 1)C!*
+he superficial part of scalp is drained (" supra or(ital &supra trochlear
veins.
Supratrochlear vein@ it starts from the venous net,ork connected to the
frontal tri(utaries of the superficial temporal vein. it descends near the
midline to the (rid&e of the nose.,here it unites ,ith the supraor(ital vein to
form the facial vein near the medial canthus of the e"e.
Supraor(ital vein (e&ins near the D"&omatic process of the frontal
(one.passes mediall" piercin& the or(icularis oculi&unites ,ith the
supratrochlear vein .frontal &supra or(ital veins anastomose throu&h ,ide
venous nets ,ith the other veins of the scalp.superficial temporal.posterior
auricular &occipital veins.
SI37S!S 21 +5! $7:)8)+!:
+he (lood of the (rain and the e"e is collected (" s"stem of specialiDed vein
in the duramater called sinuses. +hese sinuses are non collapsi(le and are
formed (" the dense ri&id and inelastic tissue of the duramater. +he" drain
eventuall" into the internal -u&ular vein (ut there are numerous
communications (et,een the sinuses and the e/tracranial vein.

S79!:I2: S)>I++)0 SI37S
+his sinus commences in the re&ion of crista &ali of the ethmoid (one and
curves posteriorl" in the midline over the frontal. parietal and occipital
(ones. 2n its ,a" it receives numerous veins from the conve/it" of the
(rain.
)rachnoid &ranulations are small cauliflo,er like e/tension that protrude
into the lateral aspects of the superior sa&&ital sinus .csf leaks (ack across
the arachnoid mem(rane throu&h these archnoid &ranulations to enter the
venous (lood of the superior sa&ittal sinus.
I31!:I2: S)>I++)0 SI37S
) narro, sinus. enclosed in the lo,er free (order of a sickle shape median
fold of the dura. the fal/ cere(ri ,hich separates the t,o hemispheres of the
cere(rum.
S+:)I>5+ SI37S
) rou&hl" horiDontal fold of the dura (et,een the cere(rum and
cere(ellum.meets the inferior sa&&ital sinus -oins ,ith a deep vein of (rain
&continues (ack,ards &do,n,ards as the strai&ht sinus.it unites ,ith the
superior sa&&ital sinus at the inner occipital eminence.
2CCI9I+)0 SI37S*
+his small vein (e&ins on either side of the &reat occipital foramen
&ascends in the midline.it ends at the inner occipital eminence.
+:)3SV!:S! SI37S4
+he point ,here the superior sa&&ital sinus .strai&ht sinus .&occipital sinus
unite is called the confluence of the sinuses.from here the (lood is drained
(" the paired transverse sinus..sometimes the strai&ht &superior sa&&ital
sinus do not -oin (ut continue each into one transverse sinus.even if the" -oin
also a &reater amount of (lood usuall" enters into the ri&ht transverse sinus
than the left. as a conseFuence the ri&ht internal -u&ular vein is often much
lar&er than the left.
+he transverse sinus runs almost horiDontall" across the occipital (one
&then over the temporal (one to the point ,here the superior crest of the
temporal p"ramid commences.from this point the transverse sinus continues
in an s shaped curve as the si&moid sinus.descendin& to,ards the cranial
(ase .the si&moid sinus continues throu&h the -u&ular foramen into the
internal -u&ular vein.
C)V!:327S SI37S* it is a lar&e venous space situated in the middle
cranial fossa on either side of the sphenoid (one. +he floor of the sinus is
formed (" the endosteal duramater .the lateral ,all. roof. &medial ,all is
formed (" menin&eal duramater. )nteriorl" the sinus e/tends up to the
medial end of the superior or(ital fissure &posteriorl" up to the ape/ of
petrous temporal (one.
:elations ?
Structure outside the sinus@
a.superiorl" * optic tract.optic chiasma.olfactor" tract.internal carotid
arter".
(.inferiorl"*foramen lacerum & the -unction of the (od" &&reater ,in& of
sphenoid (one
c.mediall"*h"poph"sis cere(ri &sphenoidal air sinus
d.laterall"*temporal lo(e ,ith uncus
e.anteriorl"*superior or(ital fissure & the ape/ of the or(it
f.posteriorl"*ape/ of the petrous temporal & the crus cere(ri of the mid
(rain
structure in the lateral ,all of the sinus@
a.occulomotor nerve@ in the anterior part of the sinus.it divides into the
superior &inferior divisions ,hich leave the sinus (" passin& throu&h the
superior or(ital fissure
(. trochlear nerve@it enters the or(it throu&h superior or(ital fissure
c.opthalmic nerve@in the anterior part of the sinus it divides into the
lacrimal.frontal.& nasociliar" nerves
d.ma/illar" nerve@it leaves the sinus (" passin& throu&h the foramen
rotandum
e.tri&eminal &an&lion
structures passin& throu&h the centre of the sinus*
a. internal carotid arter" ,ith the venous & s"mpathetic ple/us around it.
(. )(ducent nerve@inferolateral to the internal carotid arter".
+ri(utaries or incomin& channels*
1rom the or(it@
a.superior ophthalmic vein
(. (ranch of inferior ophthalmic veinor sometimes the vein itself.
c.the central vein of retina ma" drain into the superior ophthalmic vein or
into the cavernous sinus.
1rom the (rain@
a.superficial middle cere(ral vein
(. inferior cere(ral veins
from the menin&es@
a. Sphenoparietal sinus
(. 1rontal trunk of middle menin&eal vein ,hich ma" drain into the
pter"&oid ple/us throu&h the foramen ovale or into the sphenoparietal
or cavernous sinus.
$rainin& channelsor communications@
a. +ransverse sinus throu&h the superior petrosal sinus
(. Internal -u&ular vein throu&h the inferior petrosal sinus &throu&h a
ple/us around the internal carotid arter".
c. 9ter"&oid ple/us of veins throu&h the emissar" veins passin& throu&h the
foramen ovale.foramen lacerum& the emissar" sphenoidal foramen
d. 1acial vein throu&h the superior ophthalmic vein
e. :i&ht &left cavernous sinuses communicate ,ith each other throu&h the
anterior &posterior intercavernous sinuses &throu&h the (asilar ple/us
of veins.

su%erior %e&rosa( sinus ;sinus petrosus superior) small and narro,.
connects the cavernous ,ith the transverse sinus. It runs lateral,ard and
(ack,ard. from the posterior end of the cavernous sinus. over the tri&eminal
nerve. and lies in the attached mar&in of the tentorium cere(elli and in the
superior petrosal sulcus of the temporal (one4 it -oins the transverse sinus
,here the latter curves do,n,ard on the inner surface of the mastoid part of
the temporal. It receives some cere(ellar and inferior cere(ral veins. and
veins from the t"mpanic cavit".

In!erior %e&rosa( sinus ;sinus petrosus inferior< is situated in the inferior
petrosal sulcus formed (" the -unction of the petrous part of the temporal
,ith the (asilar part of the occipital. It (e&ins in the postero@inferior part of
the cavernous sinus. and. passin& throu&h the anterior part of the -u&ular
foramen. ends in the superior (ul( of the internal -u&ular vein. +he inferior
petrosal sinus receives the internal auditor" veins and also veins from the
medulla o(lon&ata. 9ons. and under surface of the cere(ellum.

:elations* of the parts to one another in the -u&ular foramen is as follo,s*
the inferior petrosal sinus lies mediall" and anteriorl" ,ith the menin&eal
(ranch of the ascendin& phar"n&eal arter". and is directed o(liFuel"
do,n,ard and (ack,ard4 the transverse sinus is situated at the lateral and
(ack part of the foramen ,ith a menin&eal (ranch of the occipital arter". and
(et,een the t,o sinuses are the &lossophar"n&eal. va&us. and accessor"
nerves. +hese three sets of structures are divided from each other (" t,o
processes of fi(rous tissue. +he -unction of the inferior petrosal sinus ,ith
the internal -u&ular vein takes place on the lateral aspect of the nerves.

SI>82I$ SI37S* it continues mediall" from the transverse sinus & ends at
the mouth of the -u&ular foramen. +hus all venous (lood ultimatel" collected
(" the si&moid sinus drains throu&h the -u&ular foramina to the internal
-u&ular vein (elo,.
A)SI0): SI37S* it lies (elo, the $ura of the clivus. scattered in a
ple/iform fashion. It receives (lood from the cavernous sinus inferior
petrosal sinus &then drains to the verte(ral ple/us of veins throu&h the
foramen ma&num.
E*issar- Veins /emissaria01Hthe emissar" veins pass throu&h apertures in
the cranial ,all and esta(lish communication (et,een the sinuses inside the
skull and the veins e/ternal to it. Some are al,a"s present. others onl"
occasionall" so. +he principal emissar" veins are the follo,in&*
;1< ) mastoid emissar" vein. usuall" present. runs throu&h the mastoid
foramen and unites the transverse sinus ,ith the posterior auricular or ,ith
the occipital vein.
;2< ) parietal emissar" vein passes throu&h the parietal foramen and
connects the superior sa&ittal sinus ,ith the veins of the scalp.
;3< ) net@,ork of minute veins ;rete canalis hypoglossi< traverses the
h"po&lossal canal and -oins the transverse sinus ,ith the verte(ral vein and
deep veins of the neck.
;4< )n inconstant cond"loid emissar" vein passes throu&h the cond"loid
canal and connects the transverse sinus ,ith the deep veins of the neck.
;5< ) net@,ork of veins ;rete foraminis ovalis< unites the cavernous sinus
,ith the pter"&oid ple/us throu&h the foramen ovale.
;6< +,o or three small veins run throu&h the foramen lace rum and connect
the cavernous sinus ,ith the pter"&oid ple/us.
;< +he emissar" vein of the foramen of Vesalius connects the same parts.
;#< )n internal carotid ple/us of veins traverses the carotid canal and unites
the cavernous sinus ,ith the internal -u&ular vein.
;%< ) vein is transmitted throu&h the foramen cecum and connects the
superior sa&ittal
sinus ,ith the veins of the nasal cavit".
$I902IC V!I3S*
+he di%(oi# 'eins occup" channels in the diploI of the cranial (ones. +he"
are lar&e and e/hi(it at irre&ular intervals pouch@like dilatations4 their ,alls
are thin. and formed of endothelium restin& upon a la"er of elastic tissue.
1
So lon& as the cranial (ones are separa(le from one another. these veins are
confined to the particular (ones4 (ut ,hen the sutures are o(literated. the"
unite ,ith each other. and increase in siDe. +he" communicate ,ith the
menin&eal veins and the sinuses of the dura mater. and ,ith the veins of the
pericranium. +he" consist of ;1< the !ron&a(2 ,hich opens into the
supraor(ital vein and the superior sa&ittal sinus4 ;2< the an&erior &e*%ora(2
,hich is confined chiefl" to the frontal (one. and opens into the
sphenoparietal sinus and into one of the deep temporal veins. throu&h an
aperture in the &reat ,in& of the sphenoid4 ;3< the %os&erior &e*%ora(2
,hich is situated in the parietal (one. and ends in the si&moid sinus. throu&h
an aperture at the mastoid an&le of the parietal (one or throu&h the mastoid
foramen4 & also communicates ,ith the occipital vein and ;4< the o##i%i&a(2
the lar&est of the four. ,hich is confined to the occipital (one. and opens
either e/ternall" into the occipital vein. or internall" into the transverse sinus
or into the confluence of the sinuses ;torcular Herophili<.
2

Veins of the diploe
S9:!)$ 21 I31!C+I23 +5:27>5
V!327S $:)I3)>!
C233!C+I23S A!+C!!3 !E+:)C:)3I)0 V!I3S &
I3+:)C:)3I)0 V!I3S*
+here are 4 ,a"s (" ,hich e/tracranial veins communicate ,ith the
intracranial veins.
1. !missar" veins
2. $iploic veins
3. Venous ple/us surroundin& internal carotid arter" & cranial nerves
4. +hrou&h superior ophthalmic vein or facial vein and retromandi(ular
vein.
)s alread" mentioned there are various 1.emissar" veins found in the head
& neck re&ion. (ut the most important of our concern is the connection
(et,een pter"&oid ple/us & cavernous sinus throu&h foramina ovale .
foramina lacerum . & sphenoidal foramina.
9ter"&oid ple/us of veins is drained (" posterior superior alveolar vein
,hich drains the posterior part of the ma/illa.so infection from this re&ion
can directl" enter into cavernous sinus throu&h the pter"&oid ple/us
1acial vein throu&h the deep facial vein communicates ,ith the pter"&oid
ple/us.
2. $iploic veins*
1our diploic veins are present
1rontal diploic vein@ connects to superior sa&ittal sinus & to the frontal vein
)nterior temporal vein@ connects to sphenoparietal sinus & deep temporal
vein
9osterior temporal vein ? connects to si&moid sinus &to the occipital vein
2ccipital diploic vein@ connects to transverse sinus & to the occipital veins
3. venous ple/us *
+he veins that connect the sinuses & the e/tracranial veins alon& the internal
carotid arter" & man" of the cranial nerves are loosel" connected ,ith the
surroundin& tissue & therefore collapsi(le. +his acts as compressi(le
cushionin& allo,in& for the chan&es in the volume of the arter" durin& its
pulsation.
+he internal carotid ple/us of veins connects the cavernous sinus ,ith the
pter"&oid ple/us of veins . another important ple/us of vein accompanies the
h"po&lossal nerve throu&h the h"po&lossal canal.
5. 2f all the communications . those esta(lished (" the ophthalmic veins
are of &reatest clinical importance
+here are t,o t"pes of propa&ation of a facial throm(ophle(ities to the
cavernous sinus .one path leads from the facial vein into the superior
ophthalmic vein or sometimes rarel" into the inferior ophthalmic vein
,hich in turn passes throu&h the superior or(ital fissure. Second path
leads from the retromandi(ular vein into the pter"&oid venous ple/us
.from here throu&h the inferior or(ital fissure into the terminal part of the
inferior ophthalmic vein . & then immediatel" throu&h the superior
or(ital fissure into "he cavernous sinus.
In the first path. there ,ill (e ,arnin& si&nals like involvement of or(ital
or retro (ul(ar cellulitis in the second path,a" . there ,ill (e no ,arnin&
si&nal directl" menin&eal s"mptoms ma" occur.
1acial & retromandi(ular veins communicate (" deep as ,ell as ("
superficial anastomoses. +he anterior re&ion of the upper -a, drains into
the infraor(ital veins . ,hich anastomoses freel" ,ith the tri(utaries of
the facial vein at the infraor(ital foramen . ,here as infra or(ital vein
itself enters into the pter"&oid ple/us draned (" retromandi(ular vein.
+he posterior part of the upper -a,s drains mainl" into the posterior
superioralveolar veins ,hich are also tri(utaries of the pter"&oid ple/us
of veins
Venous (lood of the lo,er -a, is primaril" drained into the inferior
alveolar vein . a (ranch of the ma/illar" vein ,hich drains into the
retromandi(ular vein & there is also ,ide anastomoses (et,een the
inferior alveolar vein & tri(utaries of the facial vein throu&h the mental
foramen.
1acial & retromandi(ular veins are also in direct communication (" the
veins of the cheek ,hich drains for,ard to the facial vein & (ack,ard to
the retromandi(ular vein.
Spread of infection throu&h the facial vein*
+he facial vein makes clinicall" important connections ,ith the cavernous
sinus throu&h the superior ophthalmic vein. the pter"&oid ple/us .a net,ork
of small veins ,ithin the infratemporal fossa throu&h the inferior ophthalmic
&deep facial veins. Aecause of these connections. an infection of the face
ma" spread to the cavernous sinus &pter"&oid venous ple/us.
Alood from the medial an&le of the e"e. nose. &lips usuall" drains inferiorl"
throu&h the facial vein. especiall" ,hen a person is erect. & as facial vein
has no valves (lood ma" pass throu&h it in the opposite direction
conseFuentl". venous (lood from the face ma" enter the cavernous sinus.
In individuals ,ith throm(ophle(itis of the facial vein. pieces of infected
clot ma" e/tend into the intracranial venous s"stem & produces
throm(ophle(itis of the cavernous sinus.
Infection of the facial vein spreadin& to dural venous sinuses ma" result
from the lacerations of the nose or (e initiated (" pimples on the side of the
nose &upper lip. conseFuentl" the trian&ular area from the upper lip to the
(rid&e of the nose is considered the daner area o! &"e !a#e1
CAVERNOUS SINUS THROM3OSIS,
It is a serious complication of infections of the upper &lo,er face & neck
re&ion .it is more likel" to (e involved in the potentiall" fatal spread of
infection.each cavernous sinus communicates ,ith each other. ,ith
pter"&oid ple/us of veins.& superior ophthalmic vein ,hich anastomoses
,ith the facial vein.these ma-or veins drain teeth throu&h the posterior
superior &inferiorvein & lips throu&h the superior & inferior la(ial
veins.none of the veins that communicate ,ith the cavernous sinus have
valves to prevent the retro&rade (lood flo, (ack into the cavernous sinus
.therefore dental infection that drain throu&h this ma-or veins initiate the
inflammator" respone resultin& in (lood stasis .throm(us formation.&
increasin& e/tra vascular fluid pressure. Increased pressure can chan&e the
direction of (lood flo,.ena(lin& the transport of this throm(us into the
venous sinuses causin& cavernous sinus throm(osis.

3eedle track contamination can also result in spread of infection throu&h
pter"&oid ple/us of veins ,hile administratin& posterior superior alveolar
(lock incorrectl".non odonto&enic infections ori&inatin& from the dan&er
trian&le of face i.e or(it . nasal re&ion & para nasal sinus.
Si&ns & s"mpthoms of cavernous sinus throm(osis*
1ever.
9appiloedema
9roptosis
opthalmople&ia
$ro,siness.
:apid pulse.
0oss of function of a(ducent nerve.
$iplopia.
!dema of e"elids. con-unctiva.
!/opthalmos. dependin& on the infection
$ama&e to other cranial nerves. like occulomotor &trochlear as ,ell
as ophthalmic &ma/illar" division
8enin&itis.
8ost common sites of primar" infection@
1. 1acial infection* medial third of face around the e"es & nose

2phthalmic vein.
2 .sphenoid & ethmoid sinus infection@ emissar" veins & superior
ophthalmic vein.
3. $ental infection ? pter"&oid ple/us of veins.
4. 2titis media & complication@ mastoiditis
:!1!:!3C!S@
1. Clinical )natom" for medical students@ :ichard S. Snell.
si/th edition.
2. Clinicall" 2riented )natom"@ 6eith 0. 8oore. )rthur 1.$alle". fifth
edition.
3. >ra"Bs )natom"@ 5enr" >ra". thirt" ninth edition.
4. 0astBs )natom" re&ional & applied@ Chumm" S. Sinnatam(".
eleventh edition.
5. +he )natomical Aasis 2f $entistr"@ Aernard 0ie(&ott. second edition
pa&e no 3%4@3%5
6. 7nusual Venous $raina&e 9attern of 1ace* ) Case :eport. Me"ra2S1
4au( 51M1 and Das S1 = )nat. Soc. India 52;1< 64@65 ;2''3<