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Duplication of the lower third of the internal jugular vein – case report and surgical implications
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British Journal of Oral and Maxillofacial Surgery 52 (2014) 461–463
Short communication
Duplication of the lower third of the internal jugular vein – case report and surgical implications Ishpinder Bachoo a , Barrie Evans b,∗ a b
University Hospital Southampton NHS Foundation Trust, Tremona Road, Southampton SO16 6YD, United Kingdom University Hospital Southampton NHS Foundation Trust, Southampton General Hospital, Tremona Road, Southampton SO16 6YD, United Kingdom
Accepted 27 February 2014 Available online 27 March 2014
Abstract Duplication of the internal jugular vein is rare with a reported incidence of 0.4%. Most are located in the upper third and are almost always unilateral, duplication of the lower third is less common. In the case presented the vein divided above the omohyoid muscle with one branch passing superficial and the other deep to the muscle. Failure to recognise this anomaly could result in iatrogenic damage to the superficial branch in particular, with brisk and unexpected haemorrhage during neck dissection. © 2014 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. Keywords: Internal jugular vein; Duplication; Omohyoid; Neck dissection; Anatomy
Introduction Neck dissection is routinely done as part of the management of malignant disease of the upper aerodigestive tract. It is used to treat metastases in the neck and in selected patients with no signs of neck disease. The classic radical neck dissection, first described by Crile in 1906 and later popularised by Hayes Martin, has been superseded by more conservative approaches.1,2 Identification of the internal jugular vein and the omohyoid muscle is integral to every neck dissection. The two bellies of the omohyoid, which are linked by its intermediate tendon, pass deep to the sternocleidomastoid muscle at
the junction of its middle and lower thirds and superficial to the internal jugular vein.3 Notwithstanding its variable position, the omohyoid arbitrarily divides the “surgical neck” into levels III and IV.2 In view of the relation to the sternocleidomastoid muscle and the internal jugular vein, the omohyoid muscle is used to guide the depth of dissection during cervical lymphadenectomy. Surgeons may gently and blindly dissect deep to the sternocleidomastoid muscle and superficial to the omohyoid in the knowledge that the vein is safe, deep to the omohyoid.1
Case report
∗ Corresponding author at: Department of Oral and Maxillofacial Surgery, Mailpoint 58, C-level, Centre Block, University Hospital Southampton NHS Foundation Trust, Tremona Road, Southampton SO16 6YD, United Kingdom. Tel.: +1 07931527628. E-mail addresses: ish [email protected] (I. Bachoo), [email protected] (B. Evans).
Our patient was a 60-year-old woman with a T4 N2a M0 polymorphous low-grade adenocarcinoma involving the left posterior mandible, maxilla, and adjacent infratemporal fossa. The agreed treatment plan was wide local excision, ipsilateral level I–III neck dissection, and reconstruction with an osseomyocutaneous fibula free flap followed by radiotherapy.
http://dx.doi.org/10.1016/j.bjoms.2014.02.021 0266-4356/© 2014 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
462
I. Bachoo, B. Evans / British Journal of Oral and Maxillofacial Surgery 52 (2014) 461–463
fenestrations. Only 4 were duplications and one of them was bilateral. Most duplications and fenestrations occur in the upper third of the vessel and are associated with the spinal accessory nerve, which either passes between the 2 divisions or deep to both divisions.4,6,7 Duplication at the level of the lower third appears to be the least common anomaly. We know of 3 previously reported cases that describe the 2 branches passing superficial and deep to the omohyoid muscle.8–10 Three theories have been suggested to explain fenestration or duplication of the vein: the vascular, neural, and bony hypotheses. The vascular and neural theories are based on the relation between the vein and the spinal accessory nerve, and therefore relate only to the division of the vessel in the upper third of the neck. The bony hypothesis relates to anomalies of the vein at the level of the jugular foramen.4,7 None of them unfortunately address low bifurcations and their particular relation to the omohyoid muscle. Downie et al.5 suggested the possibility of a local failure of “vascular pruning” during foetal development in which unnecessary vessels are eliminated in view of their position in the “vascular hierarchy”. We report this case to highlight this anatomical variant and to emphasise the need for caution when dissecting blindly deep to the sternocleidomastoid muscle.
Conflict of interest statement Fig. 1. Low duplication of the left internal jugular vein straddling the omohyoid muscle (IJV: internal jugular vein; SCM: sternocleidomastoid muscle retracted; OH: omohyoid muscle).
At operation we identified a duplication of the internal jugular vein in the lower third of the neck with one branch passing superficial and the other deep to the omohyoid muscle. Both branches drained into the subclavian vein (Fig. 1).
Discussion Duplication of the internal jugular vein can be considered a rare anomaly with a reported incidence of 0.4% in unilateral neck dissection.4 The true incidence of its duplication is difficult to assess as the terms duplication, partial duplication, and fenestration have been used interchangeably. It is now accepted that duplication or bifurcation refers to branches of the vein that remain separate through their entire course and drain separately into the subclavian vein, whereas fenestration refers to cases where the branches reunite to form one single vessel proximal to the subclavian vein.5 Duplication and fenestration are almost always unilateral, in keeping with the lack of symmetry of cervical venous anomalies.4,5 Duplication of the internal jugular vein is less common than fenestration. In their review of publications up to 2009, Oztürk and Talas6 identified 14 cases of duplications or
The authors would like to state there is no conflict of interest issue with this article.
Ethics statement/confirmation of patient permission This article was written in approval with Southampton University NHS Trust Ethical Guidelines. This article contains no identifying information regarding the patient and therefore consent for publication is not required.
References 1. Leemans R, Eerenstein S, Paleri V. Neck dissection. In: Watkinson JC, Gilbert RW, editors. Stell & Maran’s textbook of head and neck surgery and oncology. 5th ed. London: Hodder Arnold; 2012. p. 698–713. 2. Brennan PA. Neck dissection. In: Langdon J, Patel M, Ord R, Brennan P, editors. Operative oral and maxillofacial surgery. 2nd ed. London: Hodder Arnold; 2009. p. 341–7. 3. Standring S. The neck. In: Grays anatomy: the anatomical basis of clinical practice. 40th ed. London: Churchill Livingstone Elsevier; 2008. p. 435–66. 4. 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.
I. Bachoo, B. Evans / British Journal of Oral and Maxillofacial Surgery 52 (2014) 461–463 5. Downie SA, Schalop L, Mazurek JN, et al. Bilateral duplicated internal jugular veins: case study and literature review. Clin Anat 2007;20:260–6. 6. Oztürk NC, Talas DÜ. Fenestration of internal jugular vein and relation to spinal accessory nerve: case report and review of the literature. Clin Anat 2010;23:883–4. 7. Alaani A, Webster K, Pracy JP. Duplication of internal jugular vein and relation to the spinal accessory nerve. Br J Oral Maxillofac Surg 2005;43:528–31.
463
8. Mu˜noz-Guerra MF, Campo FR, Gías LN, et al. Double internal jugular vein. Plast Reconstr Surg 2000;106:1434–5. 9. Uemara M, Takemura A, Tamada Y, et al. A case of right partial and double internal jugular veins. Anat Sci Int 2006;81:65–9. 10. González-García R, Román-Romero L, de la Plata MM. The rare phenomenon of internal jugular vein duplication. Otolaryngol Head Neck Surg 2007;137:847–8.
British Journal of Oral and Maxillofacial Surgery 52 (2014) 461–463
Short communication
Duplication of the lower third of the internal jugular vein – case report and surgical implications Ishpinder Bachoo a , Barrie Evans b,∗ a b
University Hospital Southampton NHS Foundation Trust, Tremona Road, Southampton SO16 6YD, United Kingdom University Hospital Southampton NHS Foundation Trust, Southampton General Hospital, Tremona Road, Southampton SO16 6YD, United Kingdom
Accepted 27 February 2014 Available online 27 March 2014
Abstract Duplication of the internal jugular vein is rare with a reported incidence of 0.4%. Most are located in the upper third and are almost always unilateral, duplication of the lower third is less common. In the case presented the vein divided above the omohyoid muscle with one branch passing superficial and the other deep to the muscle. Failure to recognise this anomaly could result in iatrogenic damage to the superficial branch in particular, with brisk and unexpected haemorrhage during neck dissection. © 2014 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. Keywords: Internal jugular vein; Duplication; Omohyoid; Neck dissection; Anatomy
Introduction Neck dissection is routinely done as part of the management of malignant disease of the upper aerodigestive tract. It is used to treat metastases in the neck and in selected patients with no signs of neck disease. The classic radical neck dissection, first described by Crile in 1906 and later popularised by Hayes Martin, has been superseded by more conservative approaches.1,2 Identification of the internal jugular vein and the omohyoid muscle is integral to every neck dissection. The two bellies of the omohyoid, which are linked by its intermediate tendon, pass deep to the sternocleidomastoid muscle at
the junction of its middle and lower thirds and superficial to the internal jugular vein.3 Notwithstanding its variable position, the omohyoid arbitrarily divides the “surgical neck” into levels III and IV.2 In view of the relation to the sternocleidomastoid muscle and the internal jugular vein, the omohyoid muscle is used to guide the depth of dissection during cervical lymphadenectomy. Surgeons may gently and blindly dissect deep to the sternocleidomastoid muscle and superficial to the omohyoid in the knowledge that the vein is safe, deep to the omohyoid.1
Case report
∗ Corresponding author at: Department of Oral and Maxillofacial Surgery, Mailpoint 58, C-level, Centre Block, University Hospital Southampton NHS Foundation Trust, Tremona Road, Southampton SO16 6YD, United Kingdom. Tel.: +1 07931527628. E-mail addresses: ish [email protected] (I. Bachoo), [email protected] (B. Evans).
Our patient was a 60-year-old woman with a T4 N2a M0 polymorphous low-grade adenocarcinoma involving the left posterior mandible, maxilla, and adjacent infratemporal fossa. The agreed treatment plan was wide local excision, ipsilateral level I–III neck dissection, and reconstruction with an osseomyocutaneous fibula free flap followed by radiotherapy.
http://dx.doi.org/10.1016/j.bjoms.2014.02.021 0266-4356/© 2014 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
462
I. Bachoo, B. Evans / British Journal of Oral and Maxillofacial Surgery 52 (2014) 461–463
fenestrations. Only 4 were duplications and one of them was bilateral. Most duplications and fenestrations occur in the upper third of the vessel and are associated with the spinal accessory nerve, which either passes between the 2 divisions or deep to both divisions.4,6,7 Duplication at the level of the lower third appears to be the least common anomaly. We know of 3 previously reported cases that describe the 2 branches passing superficial and deep to the omohyoid muscle.8–10 Three theories have been suggested to explain fenestration or duplication of the vein: the vascular, neural, and bony hypotheses. The vascular and neural theories are based on the relation between the vein and the spinal accessory nerve, and therefore relate only to the division of the vessel in the upper third of the neck. The bony hypothesis relates to anomalies of the vein at the level of the jugular foramen.4,7 None of them unfortunately address low bifurcations and their particular relation to the omohyoid muscle. Downie et al.5 suggested the possibility of a local failure of “vascular pruning” during foetal development in which unnecessary vessels are eliminated in view of their position in the “vascular hierarchy”. We report this case to highlight this anatomical variant and to emphasise the need for caution when dissecting blindly deep to the sternocleidomastoid muscle.
Conflict of interest statement Fig. 1. Low duplication of the left internal jugular vein straddling the omohyoid muscle (IJV: internal jugular vein; SCM: sternocleidomastoid muscle retracted; OH: omohyoid muscle).
At operation we identified a duplication of the internal jugular vein in the lower third of the neck with one branch passing superficial and the other deep to the omohyoid muscle. Both branches drained into the subclavian vein (Fig. 1).
Discussion Duplication of the internal jugular vein can be considered a rare anomaly with a reported incidence of 0.4% in unilateral neck dissection.4 The true incidence of its duplication is difficult to assess as the terms duplication, partial duplication, and fenestration have been used interchangeably. It is now accepted that duplication or bifurcation refers to branches of the vein that remain separate through their entire course and drain separately into the subclavian vein, whereas fenestration refers to cases where the branches reunite to form one single vessel proximal to the subclavian vein.5 Duplication and fenestration are almost always unilateral, in keeping with the lack of symmetry of cervical venous anomalies.4,5 Duplication of the internal jugular vein is less common than fenestration. In their review of publications up to 2009, Oztürk and Talas6 identified 14 cases of duplications or
The authors would like to state there is no conflict of interest issue with this article.
Ethics statement/confirmation of patient permission This article was written in approval with Southampton University NHS Trust Ethical Guidelines. This article contains no identifying information regarding the patient and therefore consent for publication is not required.
References 1. Leemans R, Eerenstein S, Paleri V. Neck dissection. In: Watkinson JC, Gilbert RW, editors. Stell & Maran’s textbook of head and neck surgery and oncology. 5th ed. London: Hodder Arnold; 2012. p. 698–713. 2. Brennan PA. Neck dissection. In: Langdon J, Patel M, Ord R, Brennan P, editors. Operative oral and maxillofacial surgery. 2nd ed. London: Hodder Arnold; 2009. p. 341–7. 3. Standring S. The neck. In: Grays anatomy: the anatomical basis of clinical practice. 40th ed. London: Churchill Livingstone Elsevier; 2008. p. 435–66. 4. 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.
I. Bachoo, B. Evans / British Journal of Oral and Maxillofacial Surgery 52 (2014) 461–463 5. Downie SA, Schalop L, Mazurek JN, et al. Bilateral duplicated internal jugular veins: case study and literature review. Clin Anat 2007;20:260–6. 6. Oztürk NC, Talas DÜ. Fenestration of internal jugular vein and relation to spinal accessory nerve: case report and review of the literature. Clin Anat 2010;23:883–4. 7. Alaani A, Webster K, Pracy JP. Duplication of internal jugular vein and relation to the spinal accessory nerve. Br J Oral Maxillofac Surg 2005;43:528–31.
463
8. Mu˜noz-Guerra MF, Campo FR, Gías LN, et al. Double internal jugular vein. Plast Reconstr Surg 2000;106:1434–5. 9. Uemara M, Takemura A, Tamada Y, et al. A case of right partial and double internal jugular veins. Anat Sci Int 2006;81:65–9. 10. González-García R, Román-Romero L, de la Plata MM. The rare phenomenon of internal jugular vein duplication. Otolaryngol Head Neck Surg 2007;137:847–8.