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Empty fenestration of the internal jugular vein: a rare phenomenon
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British Journal of Oral and Maxillofacial Surgery 53 (2015) 78–80
Short communication
Empty fenestration of the internal jugular vein: a rare phenomenon Alexandre Pegot a,b , Benjamin Guichard a , Jean-Marc Peron a , Olivier Trost a,∗ a
Department of Oral and Maxillofacial Surgery, University Hospital of Rouen, Charles Nicolle Hospital, 1 rue de Germont, F-76000 Rouen, France Department of Plastic, Reconstructive and Hand Surgery, University Hospital of Rouen, Charles Nicolle Hospital, 1 rue de Germont, F-76000 Rouen, France
b
Accepted 5 September 2014 Available online 29 September 2014
Abstract Though there are common variations of the internal jugular vein (IJV), fenestrations are extremely rare. The lateral branch of the accessory nerve classically goes through the fenestration. We report a case of an empty fenestration of the IJV that was discovered during clearance of cervical lymph nodes. Original operative and radiographic images are shown. © 2014 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Keywords: Fenestration; Internal jugular vein; Neck dissection; Anatomy; Surgery; Variation
Introduction Among variations in the internal jugular vein (IJV), fenestrations are rare but they can have clinical consequences as in most cases the external ramus of the accessory nerve goes through the fenestration. We report a case of empty fenestration of the IJV.
Case report A 58-year-old woman was referred to our department for the management of a squamous cell carcinoma of the tongue. A misdiagnosed fenestration of the left internal jugular vein was discovered during clearance of cervical lymph nodes (Fig. 1). The IJV emerged from underneath the posterior belly of the digastric muscle, and divided 4 cm below into a ventral and dorsal trunk. The dorsal trunk was thinner. No structure was identified in the fenestration (in particular the external ramus
∗
Corresponding author. Tel.: +33 2 32 88 81 46; fax: +33 2 32 88 83 51. E-mail address: [email protected] (O. Trost).
of the accessory nerve was noted to be over it). The inferior thyroid and facial veins joined the ventral trunk separately. Both trunks fused at the level of the hyoid bone, and constituted a single vein that rejoined the left subclavian vein. On the other side we could see no anatomical feature of the IJV between the posterior belly of the digastric muscle and the omohyoid muscle. Retrospective analysis of the computed tomographic (CT) image showed the variation. The horizontal section at the level of the carotid sinus showed both trunks interposed between the arteries and the medial aspect of the sternocleidomastoid muscle. The right IJV was completely independent, as seen during operation (Fig. 2). An original 3-dimensional reconstruction is shown in Fig. 3.
Discussion Fenestrations of the IJV are rare, and to our knowledge only a few cases have been reported. Together with duplications they can occur in 0.4% to 3.3% of patients,1 and the terms “fenestration” and “duplication” are sometimes used interchangeably. However, Downie et al.2 stated that “dupli-
http://dx.doi.org/10.1016/j.bjoms.2014.09.005 0266-4356/© 2014 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
A. Pegot et al. / British Journal of Oral and Maxillofacial Surgery 53 (2015) 78–80
79
Fig. 1. Left operative view showing the empty fenestration (F) of the internal jugular vein. The lateral branch of the accessory nerve (arrow) crossed the vein over the fenestration.
cations” consist of 2 veins that result from the division of a unique trunk that emerges at the jugular foramen, and they join the subclavian vein separately. In the case of “fenestration”, both trunks fuse again and rejoin the subclavian vein as a single vein (“stepped duplication” as in our case). We did not identify any structure in the fenestration and, to our knowledge, only one similar case has previously been
Fig. 2. Computed tomography, horizontal section, at the level of the hyoid bone. On the left side, ventral (V) and dorsal (D) trunks were interposed between the carotid sinus (CS) and the sternocleidomastoid muscle (SCM). On the right side, the internal jugular vein (IJV) was completely independent (R). A voluminous necrotic adenopathy (A) was visible in front of the vein, as seen during the operation. We could see no anatomical feature of the right IJV.
Fig. 3. Computed tomography, left view, 3-dimensional reconstruction. The internal jugular vein (in blue) was divided in front of the carotid sinus.
reported.3 In most cases the lateral branch of the accessory nerve went through the fenestration. More rarely, the omohyoid muscle or branches of the cervical plexus were involved.1–4 The ontogenesis of IJV fenestrations is not clear,1 and 3 theories have been proposed. In the vascular theory, the fenestration results from inadequate condensation of the embryonic capillary plexus. According to the neural theory the lateral branch of the accessory nerve migrates through the IJV during its embryonic development. Finally, in the bony theory, aberrant ossifications of the jugular foramen could provide bony bridges that are responsible for variable venous partitioning. None of these hypotheses satisfactorily explains our case. Fenestrations of the IJV can have serious clinical consequences.1–5 The IJV is a common site for insertion of a central venous line, but in case of a fenestration, difficulties in insertion of the catheter could cause vascular injury together with cervical bleeding or a haematoma. The IJV is also an essential radiological landmark. A misdiagnosed variation could be erroneously interpreted as a thrombosis or adenopathy. In neck dissections, such variations could greatly increase the risks of bleeding, or make complete clearance of lymph nodes impossible, particularly if the patient has previously been treated with radiation. The IJV is also often used as a recipient vein for a free flap and some fenestrations could increase operative difficulties and morbidity. In conclusion, fenestrations of the IJV are rare, but should be kept in mind because of their potential clinical effects.
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A. Pegot et al. / British Journal of Oral and Maxillofacial Surgery 53 (2015) 78–80
Conflict of interest We have no conflict of interest. Ethics statement/confirmation of patients’ permission Not required. Acknowledgement The authors thank Richard Medeiros, Rouen University Hospital Medical Editor for editing the manuscript. The authors thank Cécile Pinson, resident in radiology, for the treatment of the original CT-scan pictures.
References 1. Prades JM, Timoshenko A, Dumollard JM, et al. High duplication of the internal jugular vein: clinical incidence in the adult and surgical consequences, a report of three clinical cases. Surg Radiol Anat 2002;24: 129–32. 2. Downie SA, Schalop L, Mazurek JN, et al. Bilateral duplicated internal jugular veins: case study and literature review. Clin Anat 2007;20: 260–6. 3. Kapre M, Mangalgiri AS. Clinical importance of duplication of internal jugular vein. Indian J Otolaryngol Head Neck Surg 2012;64:386–8. 4. Munoz Guerra MF, Campo FR, Gias LN, et al. Double internal jugular vein. Plast Reconstr Surg 2000;106:1434–5. 5. Towbin AJ, Kanal E. A review of two cases of fenestrated internal jugular veins as seen by CT angiography. AJNR Am J Neuroradiol 2004;25:1433–4.
British Journal of Oral and Maxillofacial Surgery 53 (2015) 78–80
Short communication
Empty fenestration of the internal jugular vein: a rare phenomenon Alexandre Pegot a,b , Benjamin Guichard a , Jean-Marc Peron a , Olivier Trost a,∗ a
Department of Oral and Maxillofacial Surgery, University Hospital of Rouen, Charles Nicolle Hospital, 1 rue de Germont, F-76000 Rouen, France Department of Plastic, Reconstructive and Hand Surgery, University Hospital of Rouen, Charles Nicolle Hospital, 1 rue de Germont, F-76000 Rouen, France
b
Accepted 5 September 2014 Available online 29 September 2014
Abstract Though there are common variations of the internal jugular vein (IJV), fenestrations are extremely rare. The lateral branch of the accessory nerve classically goes through the fenestration. We report a case of an empty fenestration of the IJV that was discovered during clearance of cervical lymph nodes. Original operative and radiographic images are shown. © 2014 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Keywords: Fenestration; Internal jugular vein; Neck dissection; Anatomy; Surgery; Variation
Introduction Among variations in the internal jugular vein (IJV), fenestrations are rare but they can have clinical consequences as in most cases the external ramus of the accessory nerve goes through the fenestration. We report a case of empty fenestration of the IJV.
Case report A 58-year-old woman was referred to our department for the management of a squamous cell carcinoma of the tongue. A misdiagnosed fenestration of the left internal jugular vein was discovered during clearance of cervical lymph nodes (Fig. 1). The IJV emerged from underneath the posterior belly of the digastric muscle, and divided 4 cm below into a ventral and dorsal trunk. The dorsal trunk was thinner. No structure was identified in the fenestration (in particular the external ramus
∗
Corresponding author. Tel.: +33 2 32 88 81 46; fax: +33 2 32 88 83 51. E-mail address: [email protected] (O. Trost).
of the accessory nerve was noted to be over it). The inferior thyroid and facial veins joined the ventral trunk separately. Both trunks fused at the level of the hyoid bone, and constituted a single vein that rejoined the left subclavian vein. On the other side we could see no anatomical feature of the IJV between the posterior belly of the digastric muscle and the omohyoid muscle. Retrospective analysis of the computed tomographic (CT) image showed the variation. The horizontal section at the level of the carotid sinus showed both trunks interposed between the arteries and the medial aspect of the sternocleidomastoid muscle. The right IJV was completely independent, as seen during operation (Fig. 2). An original 3-dimensional reconstruction is shown in Fig. 3.
Discussion Fenestrations of the IJV are rare, and to our knowledge only a few cases have been reported. Together with duplications they can occur in 0.4% to 3.3% of patients,1 and the terms “fenestration” and “duplication” are sometimes used interchangeably. However, Downie et al.2 stated that “dupli-
http://dx.doi.org/10.1016/j.bjoms.2014.09.005 0266-4356/© 2014 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
A. Pegot et al. / British Journal of Oral and Maxillofacial Surgery 53 (2015) 78–80
79
Fig. 1. Left operative view showing the empty fenestration (F) of the internal jugular vein. The lateral branch of the accessory nerve (arrow) crossed the vein over the fenestration.
cations” consist of 2 veins that result from the division of a unique trunk that emerges at the jugular foramen, and they join the subclavian vein separately. In the case of “fenestration”, both trunks fuse again and rejoin the subclavian vein as a single vein (“stepped duplication” as in our case). We did not identify any structure in the fenestration and, to our knowledge, only one similar case has previously been
Fig. 2. Computed tomography, horizontal section, at the level of the hyoid bone. On the left side, ventral (V) and dorsal (D) trunks were interposed between the carotid sinus (CS) and the sternocleidomastoid muscle (SCM). On the right side, the internal jugular vein (IJV) was completely independent (R). A voluminous necrotic adenopathy (A) was visible in front of the vein, as seen during the operation. We could see no anatomical feature of the right IJV.
Fig. 3. Computed tomography, left view, 3-dimensional reconstruction. The internal jugular vein (in blue) was divided in front of the carotid sinus.
reported.3 In most cases the lateral branch of the accessory nerve went through the fenestration. More rarely, the omohyoid muscle or branches of the cervical plexus were involved.1–4 The ontogenesis of IJV fenestrations is not clear,1 and 3 theories have been proposed. In the vascular theory, the fenestration results from inadequate condensation of the embryonic capillary plexus. According to the neural theory the lateral branch of the accessory nerve migrates through the IJV during its embryonic development. Finally, in the bony theory, aberrant ossifications of the jugular foramen could provide bony bridges that are responsible for variable venous partitioning. None of these hypotheses satisfactorily explains our case. Fenestrations of the IJV can have serious clinical consequences.1–5 The IJV is a common site for insertion of a central venous line, but in case of a fenestration, difficulties in insertion of the catheter could cause vascular injury together with cervical bleeding or a haematoma. The IJV is also an essential radiological landmark. A misdiagnosed variation could be erroneously interpreted as a thrombosis or adenopathy. In neck dissections, such variations could greatly increase the risks of bleeding, or make complete clearance of lymph nodes impossible, particularly if the patient has previously been treated with radiation. The IJV is also often used as a recipient vein for a free flap and some fenestrations could increase operative difficulties and morbidity. In conclusion, fenestrations of the IJV are rare, but should be kept in mind because of their potential clinical effects.
80
A. Pegot et al. / British Journal of Oral and Maxillofacial Surgery 53 (2015) 78–80
Conflict of interest We have no conflict of interest. Ethics statement/confirmation of patients’ permission Not required. Acknowledgement The authors thank Richard Medeiros, Rouen University Hospital Medical Editor for editing the manuscript. The authors thank Cécile Pinson, resident in radiology, for the treatment of the original CT-scan pictures.
References 1. Prades JM, Timoshenko A, Dumollard JM, et al. High duplication of the internal jugular vein: clinical incidence in the adult and surgical consequences, a report of three clinical cases. Surg Radiol Anat 2002;24: 129–32. 2. Downie SA, Schalop L, Mazurek JN, et al. Bilateral duplicated internal jugular veins: case study and literature review. Clin Anat 2007;20: 260–6. 3. Kapre M, Mangalgiri AS. Clinical importance of duplication of internal jugular vein. Indian J Otolaryngol Head Neck Surg 2012;64:386–8. 4. Munoz Guerra MF, Campo FR, Gias LN, et al. Double internal jugular vein. Plast Reconstr Surg 2000;106:1434–5. 5. Towbin AJ, Kanal E. A review of two cases of fenestrated internal jugular veins as seen by CT angiography. AJNR Am J Neuroradiol 2004;25:1433–4.