Common facial vein aneurysm with tributary to the external jugular vein

Clinical details

A 43-year-old female presented with a soft, non-tender swelling over the right cheek/upper neck region that had been present for the past 12 months. The swelling was noted to increase in size on Valsalva maneuver and on forward bending. There was no history of facial trauma, neck surgery, catheterization, infection, or any known coagulopathy. On physical examination, the swelling was compressible, measured approximately 4 × 4 cm, was non-pulsatile, and showed no overlying skin changes or associated lymphadenopathy. The swelling was seen to increase in size during Valsalva maneuver, as shown in Figure 1.

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Figure 1:

Clinical photograph of patient showing enlargement of the swelling during Valsalva maneuver

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Ultrasound with color Doppler was performed using a high-frequency linear transducer (10–15 MHz), scanning along the course of the facial vein and its tributaries with Doppler evaluation. It demonstrated an anechoic saccular outpouching measuring approximately 4 × 3.5 cm, located along the course of the common facial vein. Color Doppler showed low-velocity venous flow with respiratory phasicity and clear augmentation on Valsalva maneuver and distal compression, while spectral Doppler revealed a monophasic, low-resistance venous waveform. Longitudinal and transverse imaging confirmed continuity of the lesion with the proximal and distal segments of the facial venous system, and an additional communicating channel to a superficial vein consistent with an EJV tributary was identified. No intraluminal thrombus was seen. These sonographic features are consistent with previously published literature indicating that duplex ultrasound reliably detects venous aneurysms, demonstrates entrainment with respiration and Valsalva, and confirms continuity with the parent vein (Ilica AT et al.).^[2] CECT was performed using thin-slice axial imaging in arterial and venous phases with multiplanar reconstructions and maximum intensity projections. Computed tomography (CT) showed dilatation of the right lower internal jugular vein with a well-defined venous abnormality in the mid-neck region. A gross fusiform dilatation of the right common facial vein measuring approximately 28.2 × 29.3 mm was noted, showing iodine enhancement identical to the internal jugular vein on all post-contrast phases. The aneurysmal sac was located anteromedially (ventrally and slightly medially) to the internal jugular vein, with a communicating channel to a superficial vein consistent with an EJV tributary, while the cranial end of the EJV was not visualized on the available imaging dataset. These findings are typical of a fusiform common facial vein venous aneurysm with contribution from an EJV tributary, where venous-phase enhancement, anatomical continuity, and absence of arterial characteristics are key diagnostic features. These imaging findings are illustrated in Figure 2. Based on the imaging findings and absence of secondary causes, a diagnosis of idiopathic common facial vein aneurysm with drainage into the EJV was made. After discussing management options, including observation versus surgical excision, the patient opted for conservative management, which is generally preferred in asymptomatic cases, while surgery is reserved for symptomatic, thrombosed, or cosmetically significant aneurysms. A follow-up plan was established with clinical assessment and repeat duplex ultrasound examinations scheduled at 3 months and 12 months.

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Figure 2:

(a) Axial computed tomography (CT) neck venous phase reveals an aneurysmal sac along the course of the right facial vein. Contralateral common femoral vein and its tributaries, mainly the external retromandibular vein and facial vein, are normal in caliber. (b) Sagittal image reveals gross fusiform dilatation of the right common facial vein, with its axis anteriorly and inferiorly. (c) Coronal image reveals gross fusiform dilatation of the right common facial vein and shows iodine enhancement identical to the internal jugular vein on all post-contrast phases. (d and e) Axial CT neck venous phase reveals gross fusiform dilatation of the right common facial vein, with its axis medially and anteriorly. No thrombus or calcification seen. (f) Coronal CT venous phase reveals a communicating channel between the aneurysmal sac and a superficial vein, consistent with an external jugular vein tributary. The CT scan views have been specified in the figure legend as axial, sagittal, and coronal images, and have been checked for correctness.

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Anatomical and pathophysiological considerations

The common facial vein, which drains the superficial face, typically empties into the internal jugular vein. Variant anatomy, such as communicating tributaries to the EJV, is less common but clinically and surgically significant because it affects venous hemodynamics and potential routes of drainage.

Venous aneurysms may arise due to congenital weakness, inflammation, trauma, or other predisposing factors. When no cause is evident, the term idiopathic is applied (Saleen MI et al; Morton L et al).^[3,4] The existence of a common facial vein aneurysm with drainage to EJV is rare and has been reported only in a few cases or anatomical series, making detailed imaging crucial before any intervention.

Imaging strategy and diagnostic pearls

Duplex ultrasound serves as the first-line investigation in such cases, as it allows non-invasive characterization of the lesion’s morphology, assessment of venous flow dynamics including respiratory phasicity and augmentation, and confirmation of continuity with the parent venous segments. CECT plays a complementary and crucial role in detailed anatomical mapping, where multiplanar reformatted images clearly delineate the site of origin, venous drainage pathways such as EJV tributaries, the relationship of the lesion to the internal jugular vein, and help exclude associated complications including thrombosis, vascular compression, or mass effect. A combined ultrasonography + CT approach offers a comprehensive evaluation and guides patient management. Other potential diagnoses for a check/neck swelling are summarized in Table 1.

Differential diagnosis

Other potential diagnoses for a cheek/neck swelling should include:

A lesion that shows venous flow on US and venous-phase enhancement with continuity on CT strongly supports a venous aneurysm over these differentials.

Complications and management options

Venous aneurysms may be complicated by thrombosis, inflammation, or, rarely, rupture, and due to their superficial location, they may also lead to cosmetic concerns. Management is individualized based on symptoms, size, and progression of the lesion, with conservative follow-up recommended for asymptomatic, stable, and nonthrombosed aneurysms. Surgical excision with ligation of the feeding and draining veins is typically reserved for cases with cosmetic deformity, thrombosis, or rapid increase in size, while endovascular treatment may be considered in rare cases involving deeper or more complex venous anatomy.