Veins and Lymphatic drainage of the head and neck pdf - Head and Neck

600

CHAPTER 11

this part.

vical arteries, the suprascapular arteries, or both arise from

has no branches. Occasionally, however, the superficial cer

The third part of the subclavian artery usually

Branches

the brachial plexus.

in the root of the neck, it is closely related to the nerves of

der of the 1st rib, where it becomes the axillary artery. Here,

across the posterior triangle of the neck to the lateral bor

lateral border of the scalenus anterior muscle (Fig. 11.57)

The third part of the subclavian artery extends from the

Third Part of the Subclavian Artery

deep muscles of the neck.

which supplies the

deep cervical artery,

spaces, and the

which supplies the 1st and the 2nd intercostal

tal artery,

superior intercos

dome of the pleura and divides into the

runs backward over the

costocervical trunk

The

Branches

scalenus anterior muscle (Fig. 11.57).

The second part of the subclavian artery lies behind the

Second Part of the Subclavian Artery

the superior epigastric and the musculophrenic arteries.

to the sternum; in the 6th intercostal space, it divides into

(Fig. 11.57). It descends vertically one fingerbreadth lateral

behind the 1st costal cartilage and in front of the pleura

descends into the thorax

internal thoracic artery

The

back of the scapula (Fig. 11.57).

chial plexus and follows the suprascapular nerve onto the

runs laterally over the bra

suprascapular artery

The

crosses the brachial plexus (Fig. 11.57).

is a small branch that

superficial cervical artery

The

inferior parathyroid glands.

recurrent laryngeal nerve. It supplies the thyroid and the

face of the thyroid gland, where it is closely related to the

ascends to the posterior sur

inferior thyroid artery

The

terminal branches (Fig. 11.57).

is a short trunk that gives off three

thyrocervical trunk

The

The Head and Neck

pressure is of great help, and the artery is compressed against

the subclavian artery. The use of a blunt object to exert the

strong pressure downward and backward on the third part of

remember that the hemorrhage can be stopped by exerting

In severe traumatic accidents to the upper limb involving lac

Palpation and Compression of the Subclavian

Artery in Patients with Upper Limb Hemorrhage

eration of the brachial or axillary arteries, it is important to

the upper surface of the 1st rib.

C L I N I C A L N O T E S

Veins of the Head and Neck

external jugular vein.

branch, which joins the posterior auricular vein to form the

anterior branch, which joins the facial vein, and a posterior

On leaving the parotid salivary gland, it divides into an

superficial temporal and the maxillary veins (Fig. 11.39).

The retromandibular vein is formed by the union of the

Retromandibular Vein

retromandibular vein.

illary vein joins the superficial temporal vein to form the

from the pterygoid venous plexus (Fig. 11.39). The max

The maxillary vein is formed in the infratemporal fossa

Maxillary Vein

retromandibular vein.

salivary gland, where it joins the maxillary vein to form the

and the auriculotemporal nerve and then enters the parotid

scalp (Fig. 11.39). It follows the superficial temporal artery

The superficial temporal vein is formed on the side of the

Superficial Temporal Vein

drains into the internal jugular vein.

by the anterior division of the retromandibular vein, and

side of the mouth. It then crosses the mandible, is joined

the face with the facial artery and passes around the lateral

with the cavernous sinus. The facial vein descends down

(Fig. 11.39). It is connected through the ophthalmic veins

supratrochlear veins

the union of the supraorbital and

The facial vein is formed at the medial angle of the eye by

Facial Vein

Veins of the Face and the Neck

spread of infection).

to the venous sinuses (and are an important route for the

skull bones (Fig. 11.9). They connect the veins of the scalp

The emissary veins are valveless veins that pass through the

Emissary Veins

vault of the skull (Fig. 11.9).

The diploic veins occupy channels within the bones of the

Diploic Veins

are described on page 544.

and inferior petrosal sinuses (Fig. 11.9). All these sinuses

the occipital sinus, the cavernous sinuses, and the superior

straight sinus, the transverse sinuses, the sigmoid sinuses,

include the superior and inferior sagittal sinuses, the

bones, the orbit, and the internal ear. The venous sinuses

no valves. They receive tributaries from the brain, the skull

page 544). They have thick, fibrous walls, but they possess

the meningeal layer of the dura mater (Fig. 11.37A; see also

The venous sinuses are situated between the periosteal and

Venous Sinuses

neighboring venous sinuses.

and the veins of the brainstem, all of which drain into the

They consist of the cerebral veins, the cerebellar veins,

The veins of the brain are thin walled and have no valves.

Veins of the Brain

The veins of the scalp, face, and neck

emissary veins

The veins of the brain, venous sinuses, diploic veins, and

The veins of the head and neck may be divided into

■

Basic Anatomy

part is covered by the sternothyroid, sternohyoid, and

omastoid, and the parotid salivary gland. Its lower

The skin, the fascia, the sternocleid

Anterolaterally:

Relations of the Internal Jugular Vein

Directly above the inferior bulb is a bicuspid valve.

rior bulb.

infe

and another near its termination called the

rior bulb

supe

The vein has a dilatation at its upper end called the

deep cervical lymph nodes.

course, it is closely related to the

brachiocephalic vein (Figs. 11.39 and 11.57). Throughout its

vian vein behind the medial end of the clavicle to form the

and common carotid arteries. It ends by joining the subcla

the carotid sheath lateral to the vagus nerve and the internal

the jugular foramen. It then descends through the neck in

tinuation of the sigmoid sinus and leaves the skull through

from the brain, face, and neck (Fig. 11.39). It starts as a con

The internal jugular vein is a large vein that receives blood

Internal Jugular Vein

sternocleidomastoid muscle.

rior jugular vein joins the external jugular vein deep to the

is joined to the opposite vein by the jugular arch. The ante

close to the midline (Fig. 11.39). Just above the sternum, it

The anterior jugular vein descends in the front of the neck

Anterior Jugular Vein

Anterior jugular vein

from the back of the scapula

Suprascapular vein

the posterior triangle

from the skin and the fascia over

Transverse cervical vein

from the back of the scalp

Posterior external jugular vein

Tributaries

vian vein behind the middle of the clavicle.

beneath the platysma muscle, and it drains into the subcla

It descends across the sternocleidomastoid muscle and

posterior division of the retromandibular vein (Fig. 11.39).

jaw by the union of the posterior auricular vein with the

The external jugular vein is formed behind the angle of the

External Jugular Vein

601

■

omohyoid muscles, which intervene between the vein

The upper surface of the 1st rib

Inferiorly:

phrenic nerve

The scalenus anterior muscle and the

Posteriorly:

The clavicle

Anteriorly:

Relations

phatic duct on the right.

receives the thoracic duct on the left side and the right lym

it receives the external jugular vein. In addition, it often

internal jugular vein to form the brachiocephalic vein, and

at the outer border of the 1st rib (Fig. 11.57). It joins the

The subclavian vein is a continuation of the axillary vein

Subclavian Vein

(Fig. 11.110)

Middle thyroid vein

(Fig. 11.55)

Superior thyroid vein

Lingual vein

Pharyngeal veins

(Fig. 11.39)

Facial vein

(Fig. 11.30)

Inferior petrosal sinus

Tributaries of the Internal Jugular Vein

common carotid artery and the vagus nerve.

9th, 10th, 11th, and 12th cranial nerves. Below lie the

Above lie the internal carotid artery and the

Medially:

thoracic duct.

(Fig. 11.57). On the left side, it passes in front of the

bral vein, and the first part of the subclavian artery

the phrenic nerve, the thyrocervical trunk, the verte

medius, the scalenus anterior, the cervical plexus,

vical vertebrae, the levator scapulae, the scalenus

The transverse processes of the cer

Posteriorly:

the vein.

The chain of deep cervical lymph nodes runs alongside

digastric, and the spinal part of the accessory nerve.

is crossed by the stylohyoid, the posterior belly of the

and the sternocleidomastoid (Fig. 11.55). Higher up, it

■

Penetrating Wounds of the Internal Jugular Vein

the tip of the mastoid process and the angle of the jaw to the

It descends through the neck from a point halfway between

The internal jugular vein is remarkably constant in position.

tains little smooth muscle, its injury is not followed by contrac

The hemorrhage of low-pressure venous blood into the loose

connective tissue beneath the investing layer of deep cervical

fascia may present as a large, slowly expanding hematoma. Air

embolism is a serious complication of a lacerated wall of the

internal jugular vein. Because the wall of this large vein con-

tion and retraction (as occurs with arterial injuries). Moreover,

the adventitia of the vein wall is attached to the deep fascia of

the carotid sheath, which hinders the collapse of the vein. Blind

clamping of the vein is prohibited because the vagus and hypo-

glossal nerves are in the vicinity.

Internal Jugular Vein Catheterization

sternoclavicular joint. Above, it is overlapped by the anterior

caudal direction (Fig. 11.61).

eter are inserted into the vein at the apex of the triangle in a

and the medial end of the clavicle are identified. A shallow skin

sternal and clavicular heads of the sternocleidomastoid muscle

head turned to the opposite side, the triangle formed by the

muscle (Fig. 11.61). In the anterior approach, with the patient’s

the clavicle at the posterior border of the sternocleidomastoid

are introduced into the vein about two fingerbreadths above

the posterior approach, the tip of the needle and the catheter

nal and clavicular heads of the sternocleidomastoid muscle. In

ered laterally by this muscle. Just above the sternoclavicular

border of the sternocleidomastoid muscle, and below, it is cov-

joint, the vein lies beneath a skin depression between the ster-

depression usually overlies the triangle. The needle and cath-

C L I N I C A L N O T E S

602

CHAPTER 11

The Head and Neck

internal jugular vein

right brachiocephalic
vein

subclavian
vein

clavicle

catheter

sternocleidomastoid muscle

catheter

deep
fascia

phrenic
nerve

scalenus anterior muscle

internal jugular vein

vagus nerve

common carotid artery

carotid sheath

sternocleidomastoid muscle

skin

platysma
muscle

internal jugular vein

catheter

clavicular origin of
sternocleidomastoid muscle

clavicle

subclavian
vein

sternal origin of

sternocleidomastoid muscle

catheter

internal jugular vein

vagus nerve

common carotid artery

carotid sheath

sternal origin of
sternocleidomastoid muscle

FIGURE 11.61

Catheterization of the right internal jugular vein.

and the clavicle.

into the vein close to the apex of the triangle formed by the sternal and clavicular heads of the sternocleidomastoid muscle

Anterior approach. Note that the catheter is inserted

to the sternocleidomastoid muscle and the common carotid artery.

Posterior approach. Note the position of the catheter relative

Subclavian Vein Thrombosis

lower border of the clavicle at the junction of the medial third

for catheterization. The vein is slightly more medially placed on

The subclavian vein is located in the lower anterior corner of the

the condition may follow a radical mastectomy with a block dis

Spontaneous thrombosis of the subclavian and/or axillary

veins occasionally occurs after excessive and unaccustomed

use of the arm at the shoulder joint. The close relationship of

these veins to the 1st rib and the clavicle and the possibility of

repeated minor trauma from these structures are probably fac-

tors in its development.

Secondary thrombosis of subclavian and/or axillary veins is a

common complication of an indwelling venous catheter. Rarely,

section of the lymph nodes of the axilla. Persistent pain, heavi-

ness, or edema of the upper limb, especially after exercise, is a

complication of this condition.

Anatomy of Subclavian Vein Catheterization

posterior triangle of the neck (Fig. 11.62), where it lies immedi-

ately posterior to the medial third of the clavicle.

Infraclavicular Approach
Since the subclavian vein lies close to the undersurface of the

medial third of the clavicle (Fig. 11.62), this is a relatively safe site

the left side than on the right side.

Anatomy of Procedure
The needle should be inserted through the skin just below the

and outer two thirds, coinciding with the posterior border of the

origin of the clavicular head of the sternocleidomastoid mus-

cle on the upper border of the clavicle (Fig. 11.62). The needle

pierces the following structures:

■

Skin

■

Superficial fascia

■

Pectoralis major muscle (clavicular head)

■

Clavipectoral fascia and subclavius muscle

■

Wall of subclavian vein

C L I N I C A L N O T E S

(continued)

Basic Anatomy

603

The needle is pointed upward and posteriorly toward the middle

posterior to the scalenus anterior muscle and perforated the

bright red blood flow indicate that the needle has passed

The needle may hit the 1st rib, if the needle

Hitting the 1st rib:

The needle may be “walked” along the

of the suprasternal notch.

Anatomy of Problems

■

Hitting the clavicle:

lower surface of the clavicle until its posterior edge is reached.

■

is pointed downward and not upward.

■

Hitting the subclavian artery: A pulsatile resistance and

subclavian artery.

Anatomy of Complications
Refer to Figure 11.62.

■

Pneumothorax: The needle may pierce the cervical dome of

the pleura, permitting air to enter the pleural cavity. This com-

plication is more common in children, in whom the pleural

reflection is higher than in adults.

■

Hemothorax: The catheter may pierce the posterior wall of

the subclavian vein and the pleura.

■

Subclavian artery puncture: The needle pierces the wall of

the artery during its insertion.

■

Internal thoracic artery injury: Hemorrhage may occur into

the superior mediastinum.

■

Diaphragmatic paralysis: This occurs when the needle

damages the phrenic nerve.

(except the tip); the floor of the mouth and vestibule;

lower incisors); the anterior two thirds of the tongue

ethmoid sinuses; the upper and lower teeth (except the

lip (except the central part); the frontal, maxillary, and

scalp; the nose; the cheek; the upper lip and the lower

of the jaw. They receive lymph from the front of the

mandibular salivary gland just below the lower margin

These lie superficial to the sub

Submandibular nodes:

mately passes into the submandibular nodes.

over the buccinator muscle. They drain lymph that ulti

One or two nodes lie in the cheek

Buccal (facial) nodes:

gland, the auricle, and the external auditory meatus.

scalp above the parotid gland, the eyelids, the parotid

parotid salivary gland. They receive lymph from the

These are situated on or within the

Parotid nodes:

auditory meatus.

the scalp above the ear, the auricle, and the external

ear over the mastoid process. They receive lymph from

These lie behind the

Retroauricular (mastoid) nodes:

the back of the scalp.

bone on the back of the skull. They receive lymph from

These are situated over the occipital

Occipital nodes:

The regional nodes are arranged as follows:

that is embedded in the carotid sheath in the neck (Fig. 11.55).

to the back of the head and as a deep vertical terminal group

arranged as a regional collar that extends from below the chin

The lymph nodes of the head and neck (Fig. 11.40) are

Lymph Drainage of the Head and Neck

the pleura and/or internal thoracic artery by the needle pass

toid is attached to the upper border of the clavicle. At this point,

The site of penetration of the vein wall is larger, since it lies

to enter the subclavian vein at the point where the clavicle and

cm from the clavicle. The catheter is tunneled beneath the skin

The needle pierces the skin in the deltopectoral groove about 2

The Procedure in Children

the first rib cross. The more oblique approach in children mini-

mizes the possibility of entering the subclavian artery.

Supraclavicular Approach
This approach (Fig. 11.62) is preferred by many for the following

anatomic reasons.

■

at the junction of the internal jugular vein and the subclavian

vein, which makes the procedure easier.

■

The needle is pointed downward and medially toward the

mediastinum, away from the pleura, avoiding the complica-

tion of pneumothorax.

■

The catheter is inserted along a more direct course into the

brachiocephalic vein and superior vena cava.

Anatomy of the Procedure
With the patient in the Trendelenburg position (patient supine

with head tilted downward) or simple supine position and the

head turned to the opposite side, the posterior border of the

clavicular origin of sternocleidomastoid muscle is palpated (Fig.

11.62). The needle is inserted through the skin at the site where

the posterior border of the clavicular origin of sternocleidomas-

the needle lies lateral to the lateral border of scalenus anterior

muscle and above the 1st rib. The needle pierces the following

structures (Fig. 11.62):

■

Skin

■

Superficial fascia and platysma

■

Investing layer of deep cervical fascia

■

Wall of the subclavian vein

The needle is directed downward in the direction of the opposite

nipple. The needle enters the junction of the internal jugular vein

and the subclavian vein. It is important that the operator under-

stands that the pleura is not being penetrated and that it is pos-

sible for the needle to lie in a zone between the chest wall and

the cervical dome of the parietal pleura but outside the pleural

space (cavity).

Anatomic Complications
The following complications may occur as the result of damage

to neighboring anatomic structures (Fig. 11.62):

■

Paralysis of the diaphragm: This is caused by injury to the

phrenic nerve as it descends posterior to the internal jugular

vein on the surface of the scalenus anterior muscle.

■

Pneumothorax or hemothorax: This is caused by damage to

ing posteriorly and downward.

■

Brachial plexus injury: This is caused by the needle passing

posteriorly into the roots or trunks of the plexus.

Regional Nodes

■

and the gums.

604

CHAPTER 11

The Head and Neck

sternocleidomastoid
muscle

internal
jugular
vein

carotid sheath

clavicular head of
sternocleidomastoid
muscle

platysma
muscle

skin

internal
jugular vein

clavicle

catheter

investing
layer
of deep
cervical
fascia

catheter

first costal
cartilage

internal thoracic
artery

pectoralis
major (cut)

right
common
carotid
artery

vagus
nerve

phrenic
nerve

scalenus
anterior
muscle

cervical
pleura

brachial
plexus

manubrium
sterni

sternocleidomastoid
muscle (cut)

subclavian

vein

subclavian

vein

subclavian

vein

subclavian

vein

subclavius

muscle

subclavian

artery

right

brachio-

cephalic

vein

right

brachio-

cephalic

vein

brachiocephalic

artery

stoid

internal
jugular
vein

cervical
pleura

brachial
plexus

platysma
muscle

clavicle

heter

catheter

cat

subclavian

vein

subclavian

artery

right

brachio-

cephalicc

vein

clavicle

b l i

right

brachio-

cephalic

vein

internal
jugular
vein

FIGURE 11.62

Subclavian vein catheterization.

Supraclavicular approach. The catheter enters the subclavian vein close to its junction with the

Infraclavicular approach. Note the many important anatomic structures

located in this region. B.

internal jugular vein to form the brachiocephalic vein.

thoracic duct or the right lymphatic duct (Fig. 11.40).

nodes join to form the jugular trunk, which drains into the

The efferent lymph vessels from the deep cervical lymph

muscle, is mainly associated with drainage of the tongue.

which is situated close to the omohyoid

omohyoid node,

jugulo-

with drainage of the tonsil and the tongue. The

below and behind the angle of the jaw, is mainly concerned

which is located

jugulodigastric node,

regional nodes. The

(Fig. 11.49). They receive lymph from all the groups of

course of the internal jugular vein within the carotid sheath

The deep cervical nodes form a vertical chain along the

tures, including the thyroid gland.

trachea. They receive lymph from neighboring struc

These lie alongside the

Tracheal (paratracheal) nodes:

receive lymph from the larynx.

These lie in front of the larynx. They

Laryngeal nodes:

the vertebral column.

lymph from the nasal pharynx, the auditory tube, and

ynx and in front of the vertebral column. They receive

These lie behind the phar

Retropharyngeal nodes:

lobe of the ear.

skin over the lower part of the parotid gland, and the

drain lymph from the skin over the angle of the jaw, the

the external jugular vein on the side of the neck. They

These lie along the course of

Superficial cervical nodes:

front of the neck.

receive lymph from the skin and superficial tissues of the

the anterior jugular veins in the front of the neck. They

These lie along the course of

Anterior cervical nodes:

skin over the chin.

the incisor teeth, the center part of the lower lip, and the

the tongue, the floor of the anterior part of the mouth,

just below the chin. They drain lymph from the tip of

These lie in the submental triangle

Submental nodes:

■

Deep Cervical Nodes