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International Journal of Health Sciences and Research www.ijhsr.org ISSN: 2249-9571

Case Report

Unilateral Duplication of the External Jugular : A Case Report with Embryological Significance and Clinical Implications

Suresh B S1, Shivaleela C2, Kumar G V3

1Professor of Anatomy, 2Assistant Professor of Anatomy, 3Assistant Professor of Pediatrics, Sri Siddhartha Medical College, Tumkur, Karnataka, India.

Corresponding Author: Kumar G V

Received: 25/07//2014 Revised: 13/08/2014 Accepted: 16/08/2014

ABSTRACT

The external , one of the main superficial of the head and , drains blood mostly from the scalp and the . It is formed by the union of the posterior division of the with the . Here we present a case report of two external jugular veins emerging from the lower border of the on the right side in a male cadaver aged about 60years.The present case report mainly highlights the occurrence of this rare variation, its embryological basis and clinical Implications.

Key words: External jugular vein, , Retromandibular vein, Variations.

INTRODUCTION of the clavicle. It crosses the The word jugular means neck. Veins sternocleidomastoid muscle obliquely and in of the neck are superficial or deep to the the subclavian triangle, perforates the deep deep fascia. Deviation from the normal fascia. It crosses the transverse cervical pattern in the vascular system is a common nerve and its upper half runs parallel to the feature and it is far commoner in the veins great auricular nerve which ascends behind than in the arteries. The relevance and it. It varies in size, occasionally being importance of varied drainage patterns of the double. [1] The relevance and importance of veins of the head and neck warrant attention varied drainage patterns of the veins of the for their use in surgeries involving micro head and neck warrant attention for their use vascular anastomoses. The external jugular in surgeries involving micro vascular vein, one of the main superficial veins of the anastomoses. [2] The clinical importance of head and neck, drains blood mostly from the this vein lies in the fact that it is used as a scalp and the face. It is formed by the union venous manometer and for catheterization. It of the posterior division of the is important medico-legally and for surgeons retromandibular vein with the posterior who do head and neck surgeries they have to auricular vein. It begins at the level of the avoid it while executing a submandibular or in the parotid gland incision to expose the mandible. It is also a and runs down the neck towards the middle International Journal of Health Sciences & Research (www.ijhsr.org) 393 Vol.4; Issue: 9; September 2014 preferred option in the head and neck free vein. (b) Receiving the facial, lingual or the tissue transfer as the recipient vein. [3] cephalic veins as tributaries. (c) Passing over the clavicle and opening into the CASE REPORT cephalic, subclavian or internal jugular On routine dissection for veins. (d) Doubling of the vein. (e) undergraduate students in a male cadaver Formation of an annulus around the clavicle. aged about 60years in the department of The veins draining the regions of anatomy, Sri Siddhartha medical college, head and neck establish their identity only Tumkur, Karnataka, India, a unilateral after the development of . The external variation in external jugular vein was jugular vein arises as a secondary channel noticed on right side. On left side of the from a capillary plexus derived from a neck a single external jugular vein was seen. tributary of cephalic vein, from the tissues of But on right side two external jugular veins the neck and anastomoses secondarily with were seen emerging from the lower border the anterior facial vein. [5] Nayak et al of the parotid gland. Both veins cross the described a case where external jugular vein superficial surface of the sternocleido- was formed by the union of facial vein and mastoid muscle obliquely &then pierce the undivided retromandibular vein where the deep fascia of the posterior triangle just posterior auricular vein was absent and above the clavicle. Finally both join the external jugular vein had a communication separately. Posterior with cephalic vein. [6] Choudhary et al external jugular vein was seen joining the presented a case where bilaterally undivided right external jugular vein at the middle of retromandibular vein continued as external the posterior triangle. The specimen was jugular vein after receiving posterior photographed (figure-1). auricular vein and facial vein obliquely. [7] Bertha et al described a case where bilaterally, undivided retromandibular vein joined with facial vein to form a common trunk, which in turn drained into same sided superior venacava. [8] In the present case, on right side two external jugular veins are seen emerging from the lower border of the parotid gland. Both veins cross the superficial surface of the sternocleido- mastoid muscle obliquely & then pierce the deep fascia of the posterior triangle just Figure-1: Showing double external jugular vein on the right side (EJV) above the clavicle. Finally both join the PEJV- Posterior external jugular vein subclavian vein separately. Embryological aspects DISCUSSION Individual capillaries enlarge, join The external jugular vein receives with adjacent ones and form larger channels. the blood from the greater part of the face Superficial plexus of capillaries ultimately and scalp. The external jugular vein is one give rise to primary head veins which finally of the variable veins. Several variations of form superficial veins of head and neck. [9] external jugular vein have been reported by The embryology of veins of the scalp, face [4] Bergman et al which include: (a) and neck has not been clearly understood. Formation merely by the posterior auricular Disappearance of the principle cephalic vein International Journal of Health Sciences & Research (www.ijhsr.org) 394 Vol.4; Issue: 9; September 2014 formed in early embryonic life necessitates The superficial veins of the head and the formation of venous spaces which in neck, especially the external jugular vein are turn fuse and form channels and finally form increasingly being utilized for cannulation to facial and pharyngeal veins. These venous conduct diagnostic procedures or spaces enlarge at some places and diminish intravenous therapies. [11-13] The inspection, at others, which may result in variations. auscultation and Doppler sonographic Some primitive channels evolve, enlarge and examination of the jugular veins may give a form the definitive ones .Two venous clue for the diagnosis of cardiac diseases. [14] channels are observed in this region in an Ultrasound guided venipuncture is a embryo with a length of 10 mm i.e. the viable possibility in cases of variations in primitive maxillary vein and the ventral the pattern of the superficial veins. So, their pharyngeal vein which drain the rapidly knowledge is important for surgeons who do growing mandibular and the hyoid arches reconstructive surgery, [13] radiologists who into the common cardinal vein. do cathetarization and clinicians in general. Simultaneously, a small cranial tributary of [15] Veins on the right side of the neck are the primitive cephalic vein in the arm at commonly used for assessing venous stage 6 has grown larger in the pressure and for cannulation. External differentiating tissues of the neck and joins jugular vein is used by clinicians for the jugulocephalic vein which is crani dorsal therapeutic procedures and monitoring. The to the cartilaginous clavicle, which is now knowledge of variations in venous patterns surrounded by a venous ring. The in neck region is importance for surgeons in caudoclavicular part of this ring is a new order to avoid unnecessary bleeding during anastomosis whereby the definitive cephalic surgical procedures. vein overcomes its jugulocephalic detour and becomes directly continuous with the CONCLUSION subclavian vein now definitive. The old Superficial veins especially external proximal end of the primitive cephalic vein, jugular vein are increasingly used for which is the cranio dorsal part of the cannulation for diagnostic procedures as clavicular venous ring, may be recognised as well for intravenous therapies. Ultrasound a trunk of the adult external jugular vein.The guided venipuncture is a viable possibility in part ofthe venous ring which is ventral and cases of variations in patterns of superficial superficial to the clavicle i.e. the jugulo veins. Knowledge of these variations is cephalic segment of the primitive cephalic important for surgeons to perform the vein often dwindles at stage 6 and is usually reconstructive surgeries and to avoid any lost. Further, the developing external jugular intraoperative error in procedures which vein makes two connections, anterior and might lead to unnecessary complications. posterior with the facial vein and with the retromandibular vein respectively. 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How to cite this article: Suresh BS, Shivaleela C, Kumar GV. Unilateral duplication of the external jugular vein: a case report with embryological significance and clinical implications. Int J Health Sci Res. 2014;4(9):393-396.

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International Journal of Health Sciences & Research (www.ijhsr.org) 396 Vol.4; Issue: 9; September 2014