What Is Dural Ectasia?

There are two types of branches of the internal jugular vein: intracranial and extracranial.

Internal jugular vein dilatation

The jugular vein (v.jugularis interna) is the largest vein trunk in the neck. It is continuous with the intracranial sigmoid sinus at the jugular foramen. Accompany the internal carotid and common carotid arteries in the carotid sheath. To the back of the sternoclavicular joint and the subclavian vein merge into the head and arm vein. Because the wall of the internal jugular vein is attached to the carotid sheath, the lumen is often in a dilated state, which is beneficial to the return of blood. When the internal jugular vein is injured, the lumen cannot be blocked, which can lead to gas entering the vein and air embolism occurs.

Internal jugular vein dilatation anatomy

There are two types of branches of the internal jugular vein: intracranial and extracranial.

1) The intracranial branch collects blood from the meninges, brain, optics, vestibular worms, and skull through the dural sinus.

2) Extracranial branch

Facial vein: It starts from the internal iliac vein, passes obliquely downwards and backwards through the lateral side of the nasal wing and the corner of the mouth, receives the anterior branch of the posterior mandibular vein near the mandibular angle, descends to the height of the hyoid bone, and is injected into the internal jugular vein. blood. The facial veins generally have no venous valves above the plane of the mouth angle, and communicate with the intracranial cavernous sinus by the internal iliac vein, eye vein. It can also communicate with cavernous sinus through deep facial vein, pterygoid plexus, and vein under eye. Therefore, when the infection occurs on the face, especially the triangular area between the root of the nose and the mouth corners on both sides, if the infection is not handled properly (such as squeezing, etc.), the infection can be introduced into the skull through the above-mentioned channels. Therefore, this area is clinically called a dangerous triangle.

Posterior mandibular vein: It is formed by confluence of superficial temporal vein and maxillary vein in the parotid gland. Collect the returning blood from the arterial distribution area of the same name. The posterior mandibular vein is divided into anterior and posterior branches and injected into the facial vein and external jugular vein, respectively. The maxillary vein starts from the pterovenous plexus, and the pterovenous plexus communicates with the cavernous sinus through the veins of the inferior vein or oval hole and ruptured hole.

3) The external jugular vein is the largest superficial vein of the neck. It is formed by the posterior branch of the posterior mandibular vein, the posterior ear vein and the occipital vein. The sternocleidomastoid muscle is descended to the lower end and penetrating deep cervical fascia into the subclavian vein. The external jugular vein is superficial and can be seen subcutaneously. It is used as a site for injection, infusion, and blood extraction in clinical pediatrics.

Overview of Internal Jugular Vein Dilation

Internal Jugular Vein Phlebectasia is a spindle-shaped dilation of the internal jugular vein, which is different from twisted varicose veins. It was first reported by Harris in 1928, and Gerwig further clarified its characteristics in 1952. In previous reports, internal jugular vein dilatation is also known as Congenital venous cyst, Venous aneurysm, and Venectasia, Venous

ectasia), aneurysmal varicose veins (neurysmal

varix) and venous tumors (Venoma). This disease is rare in the clinic and is easily overlooked by oral and maxillofacial surgery. Its incidence, etiology and pathology, clinical manifestations, diagnosis and treatment are discussed.

Incidence of internal jugular vein dilatation

Internal jugular vein dilatation is rare clinically. So far in the literature available abroad, there are 48 cases with conclusive evidence. The actual clinical incidence must be higher than this number. The incidence of men was significantly more than that of women. Of the 48 cases, 39 were male and 9 were female. The ratio of male to female was greater than 4: 1. The disease is frequent in children, with 38 cases under the age of 10, accounting for 79.2%. Older patients can also be traced to the history of childhood outbreaks. It occurred in 38 cases on the right side, 5 cases on the left side, and 5 cases on both sides.

The dilatation of the internal jugular vein mainly occurs in the lower third of the internal jugular vein, and similar dilatations can occur in the external jugular vein, anterior jugular vein, and posterior facial vein.

The natural development of this disease has not been documented, and no rupture due to venous dilation has been reported.

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Etiology and pathology of internal jugular vein dilatation

Most internal jugular vein dilatations have no clear etiology, neither clear distal obstruction, nor local inflammation or clear history of trauma, and are considered a spontaneous disease. Some scholars believe that the residual jugular vein lymph sac is the causative factor of the disease. As we all know, the lymphatic system originates from the vein, starting from 6 lymphatic sacs, of which 2 are paired, namely the jugular vein lymph sac and posterior lymph sac; the other 2 are unpaired, except for the jugular vein lymph sac, all other lymph sacs Separate from the originating vein to establish a separate system, while the jugular vein lymph sac has always maintained a connection with the jugular vein system. If the valve between them is well developed, it can prevent blood from flowing back into the lymphatic vessels; if it is poorly developed or absent, it can cause increased pressure in the chest cavity and increase the residual lymphatic sac. There are also some explanations of the causative factors: the increased compression of the upper mediastinum, the formation of collaterals of the internal jugular vein, the anterior oblique muscle function, the compression of the jugular vein between the apex of the lung and the clavicle, and the compression of the anonymous vein , Trauma or congenital venous muscular defect.

The reason for the multiple right side has been explained as follows: the right internal jugular vein is more lateral than the left, and the innominate vein on the right is more directly in contact with the right rib than the left, so that when the right lung apex expands, Increased pressure between the clavicle head and the innominate vein produces a temporary dilation of the right internal jugular vein. Although this theory can explain the reason for the multiple occurrences on the right side, some scholars have conducted research by intubating the internal jugular vein pressure on both sides. The results show that when the pressure in the thorax increases, the internal jugular pressure on both sides Almost equal, there is no increased pressure in the internal jugular vein due to obstruction, which shakes the validity of this interpretation. In short, its exact etiology has not been fully understood so far.

Histopathological examinations mostly showed localized venous wall dilatation and normal venous structure. Some scholars believe that there are no obvious abnormalities, but Danis's research shows that the lesion's elastic tissue degenerates, localized endometrial thickening, and smooth muscle cells increase. Recent studies have shown that the muscular layer of the dilated jugular vein wall is thinner in pediatric patients, while the basal layer is absent in adult patients.

Clinical manifestations of internal jugular vein dilatation

Internal jugular vein dilatation is mainly manifested as cystic bulging in the lower third of the right neck, which is common in children. This swelling is obvious during Valsalva maneuver, with the mouth and nose closed, deep exhalation, and eustachian tube examination, so it is often found first in ENT. It can also make the swelling noticeable when you close your breath, cry, sneeze, or bend down in daily life; when you relax, the swelling disappears. Swelling is located at the posterior edge of the sternocleidomastoid muscle. When the pressure is touched from top to bottom with the hand, the swelling becomes significantly smaller and even disappears. Sometimes venous murmur is heard, but there is no pulsation, no pain, and no hairy arterial murmur.

Diagnosis and differential diagnosis of internal jugular vein dilatation

When Varsava is examined or there is an increase in intrathoracic pressure, the lower part of the neck appears to swell, and the possibility of jugular vein dilatation should be considered. Confirmation needs to proceed

Internal jugular vein dilatation (10 photos)

The earliest examination is retrograde venography or direct jugular vein puncture, but direct puncture can cause hematoma, and retrograde venography can cause vascular perforation, hematoma, thoracic duct injury, and pseudoaneurysm. Because these two methods may bring some complications, they have been eliminated clinically. Arterial angiography can also show dilated veins, but angiography in children is difficult and dangerous. In recent years, due to the development of angiography technology, especially the appearance of digital subtraction angiography (DSA), it has increased the clarity and reduced the risk. When it is clinically difficult to distinguish the arterial malformation from this area, DSA examination is necessary. Some non-traumatic tests are the main method of jugular venous dilatation, and color Doppler tests should be the first choice. It is inexpensive, non-invasive, has a wide scanning range, and can more accurately reflect the degree of disease and its relationship with surrounding structures. Enhanced CT scan has certain diagnostic value for this disease. In the reported cases, we applied magnetic resonance and magnetic resonance angiography (MRA) to show the lesions, which achieved intuitive, accurate, and multi-angle display, which may be a more ideal inspection method.

Cystic swelling in the lower part of the neck of children needs to be distinguished from branchial cleft cysts, thyroglossal cysts, dermoid cysts, cystic hydromas, venous malformations, and arteriovenous malformations. The main points of identification include: the dilatation of the internal jugular vein is only obvious when the pressure in the thorax is increased, it is not transilluminatable like cystic hydromas or other cystic tumors, and there is no pulsation or arterial hairy noise. More attention should be paid to the identification of laryngeal cysts and upper mediastinal cysts, which can also become obvious when the pressure in the chest increases. Identification methods include chest radiographs of the lower neck. The patient needs to be airless during the test to determine if the two coexist.

Treatment of internal jugular vein dilatation

Whether treatment is needed depends on the clinical symptoms of the disease and its effect on aesthetics. Because there is no particular subjective discomfort in this disease, and no reports of rupture of internal jugular veins have been reported, conservative observation should be the method currently advocated. If surgical treatment is possible due to the effect on aesthetics, the skin needs to be cut open on the clavicle, the internal jugular vein is exposed, and the ligature is cut off. When the position is too low, the sternum needs to be split. Therefore, the doctors and patients need to consider carefully before the operation, whether the swelling of the lower part of the neck only has a large effect when the air is closed, or the postoperative scar and possible complications have a large effect. Surgical resection of bilateral internal jugular vein dilation can cause cerebral edema, which is a high risk. At this time, dilatation vein compression can be used.