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An Unusual Position of Retromandibular Vein in Relation to Facial Nerve: A Rare Case Report.

1. Introduction

The retromandibular vein (RMV) is formed by the union of superficial temporal vein and maxillary vein and descends in the substance of the parotid gland. RMV is closely related with facial nerve within the parotid tissue. Identification and preservation of facial nerve is one of the crucial steps in the parotid surgery [1, 2], and RMV is one of the landmarks to identify facial nerve in parotid surgery [3]. Complications such as bleeding and damage to facial nerve may occur if the surgeon is not aware about the different anatomical variations of RMV in relation to facial nerve [4]. This study presents one of the rarest variations of relationship between RMV and facial nerve found during parotid surgery.

2. Case Report

A 24-year-old male patient presented with gradually progressive swelling in the right side of the cheek and below the earlobe for last one year with no complaint of pain, fever, redness over the skin, or any weakness of facial musculature. On physical examination, a 3 x 2 cm firm, nontender, and mobile swelling was present in the right parotid region. Ultrasound examination showed a 2.7 x 1.5 cm well-defined swelling in the superfacial lobe of the right parotid gland with minimal vascularity. A fine-needle aspiration cytology revealed pleomorphic adenoma of the right parotid gland. With this diagnosis, right adequate parotidectomy was planned. During surgery after identification of facial nerve, while tracing branches of facial nerve forwards RMV was found to be crossing the two main trunks of facial nerve remaining lateral as shown in Figure 1. All the branches of facial nerve were identified, and adequate parotidectomy was done.

3. Discussion

Facial nerve is one of the most important structures to be preserved in parotid surgery [1] as it controls the muscles of facial expression. During parotid surgery, there are important landmarks such as tragal pointer, posterior belly of digastric, stylomastoid foramen, RMV, and tympanomastoid suture line to identify facial nerve [5, 6].

Localization of RMV helps in identification and preservation of facial nerve and its branches. In most of the cases (88%), RMV is medial to facial nerve, but in some cases (11.83%), anatomical variations of RMV were found [7] and this creates risk of bleeding and damage to facial nerve [4, 6]. RMV may be found lateral to the lower division and medial to the upper division and may also be detected lying anterior to the facial nerve as a ring around the nerve branches or as a fork formed by the vein branches [1, 6, 8].

A cadaveric study was conducted to examine the correlation of an anatomy of the marginal mandibular branch of the facial nerve and its surrounding tissues [9]. This study investigated 85 facial halves and found that 83% of the specimens had inferior division of the facial nerve crossed laterally to the RMV, whereas 17% had inferior division of the facial nerve crossed medially to the RMV [9]. The study done by Kopuz et al. reported that, in 15% of the cases, the variations involved both sides [10].

4. Conclusion

An anatomical variation was found in relation between facial nerve and RMV, and this might increase the risk of bleeding and facial nerve injury during parotid surgery. Therefore, surgeons must be aware of this important fact.

https://doi.org/10.1155/2018/3919762

Conflicts of Interest

The authors declare that there are no conflicts of interest regarding the publication of this article.

References

[1] N. Bhattacharyya and M. A. Varvares, "Anomalous relationship of the facial nerve and the retromandibular vein: a case report," Journal of Oral and Maxillofacial Surgery, vol. 1, no. 57, pp. 75-76, 1999.

[2] S. Saha, S. Pal, M. Sengupta, K. Chowdhury, V. P. Saha, and L. Mondal, "Identification of facial nerve during parotidectomy: a combined anatomical and surgical study," Indian Journal of Otolaryngology and Head and Neck Surgery, vol. 66, no. 1, pp. 63-68, 2014.

[3] M. A. Babademez, B. Acar, E. Gunbey, H. Karabulut, and R. M. Karasen, "Anomalous relationship of the retromandibular vein to the facial nerve as a potential risk factor for facial nerve injury during parotidectomy," Journal of Craniofacial Surgery, vol. 21, no. 3, pp. 801-802, 2010.

[4] F. Alzahrani and K. Alqahtani, "The facial nerve versus the retromandibular vein: a new anatomical relationship," Head and Neck Oncology, vol. 4, no. 4, p. 82, 2012.

[5] A. R. Rai, R. Rai, K. Bhat, and R. Rai, "Anomalous location of facial nerve deep to parotid gland," Journal of Craniofacial Surgery, vol. 22, no. 2, pp. 652-653, 2011.

[6] D. H. Lee, T. M. Yoon, J. K. Lee, and S. C. Lim, "Facial nerve anomaly in a patient with a parotid tumor: a case report," Medicine, vol. 95, no. 18, p. e3601, 2016.

[7] M. Piagkou, M. Tzika, G. Paraskevas, and K. Natsis, "Anatomic variability in the relation between the retromandibular vein and the facial nerve: a case report, literature review and classification," Folia Morphologica, vol. 72, no. 4, pp. 371-375, 2013.

[8] G. Toure and C. Vacher, "Relations of the facial nerve with the retromandibular vein: anatomic study of 132 parotid glands," Surgical and Radiologic Anatomy, vol. 32, no. 10, pp. 957-961, 2010.

[9] D. I. Kim, S. H. Nam, Y. S. Nam, K. S. Lee, R. H. Chung, and S. H. Han, "The marginal mandibular branch of the facial nerve in Koreans," Clinical Anatomy: The Official Journal of the American Association of Clinical Anatomists and the British Association of Clinical Anatomists, vol. 22, no. 2, pp. 207-214, 2009.

[10] C. Kopuz, S. Ilgi, S. Yavuz, and S. Onderog, "Morphology of the retromandibular vein in relation to the facial nerve in the parotid gland," Cells Tissues Organs, vol. 152, no. 1, pp. 66-68, 1995.

Nabin Lageju [ID], (1) Prabhat Chandra Thakur, (2) and Pravin Kumar Jaiswal (2)

(1) Department of ENT-HNS, Nepal Police Hospital, Kathmandu, Nepal

(2) Department of Head and Neck Oncology, Nepal Cancer Hospital, Lalitpur, Nepal

Correspondence should be addressed to Nabin Lageju; lagejunabin@gmail.com

Received 1 September 2018; Revised 11 October 2018; Accepted 28 October 2018; Published 6 November 2018

Academic Editor: Andrea Gallo

Caption: FIGURE 1: Preoperative view after adequate parotidectomy showing RMV lateral to facial nerve branches.
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Title Annotation:Case Report
Author:Lageju, Nabin; Thakur, Prabhat Chandra; Jaiswal, Pravin Kumar
Publication:Case Reports in Otolaryngology
Date:Jan 1, 2018
Words:1033
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