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British Journal of Oral and Maxillofacial Surgery 53 (2015) 7880

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

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: Olivier.Trost@chu-rouen.fr (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) 7880

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.14
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.15 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) 7880

Conict of interest
We have no conflict of interest.
Ethics statement/conrmation of patients permission
Not required.
Acknowledgement
The authors thank Richard Medeiros, Rouen University Hospital Medical Editor for editing the manuscript. The authors
thank Ccile Pinson, resident in radiology, for the treatment
of the original CT-scan pictures.

References
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