Oral and plunging ranulas: What is the most effective treatment?

An unusual clinical presentation of a plunging ranula-The plunging ranula with extension to the vallecula

Key Clinical Message

A plunging ranula may present initially as an extensive vallecular cyst and correct diagnosis may be reached with the use of ultrasound, fluid aspiration for amylase detection, and MRI imaging.

Abstract

The ranula is a pseudocyst of the sublingual salivary gland and can be divided into two known subtypes. The simple ranula and plunging ranula. While the simple type can be found in the floor of the mouth, the plunging ranula usually pervades the mylohoid muscle and presents as a cervical swelling. The presented case should outline the difficulties in diagnostic and treatment of an uncommon expression of a mucocele above the mylohoid muscle without presenting either a cervical or an intraoral swelling, only extending towards the vallecula. We present a previously unreported clinical manifestation of a ranula of an 18-year old male, which extends posteriorly, remaining confined in the supramylohyoid muscle space. The cystic lesion protrudes in the oropharynx, and clinically appears as an extensive vallecular cyst. On magnetic resonance imaging the initial suspected diagnosis of a vallecular cyst was changed to the final diagnosis of a plunging ranula. The marsupialization of the cyst sac was performed. Outpatient follow-up revealed a persisting ostium, indicating a continuous extravasation of the sublingual gland. The present case report describes an unusual clinical presentation of a plunging ranula, remaining above the mylohyoid muscle and protruding into the oropharynx, misdirecting to the first suspected diagnosis of a vallecular cyst. The case highlights the useful contribution of the MRI imaging for differential diagnoses and the need for criteria to indicate further investigations.

Diagnostic Difficulties of Plunging Ranula: A Review of 18 Cases

OBJECTIVE(S)

Despite advancements in imaging techniques and cytological analysis, plunging ranula remains a challenging surgical, radiologic, and pathologic phenomenon. Of the 18 patients we evaluated at our institution, we highlight three cases that illustrate the high rate of misleading imaging and cytological results when assessing plunging ranula.

METHODS

Imaging results, biopsy findings, operative techniques, and pathological reports were reviewed from patients who had either a preoperative or postoperative diagnosis of ranula and underwent surgery by a single head and neck surgeon at a tertiary care center.

RESULTS

Of the 18 identified patients, computed tomography was correct on preoperative imaging 73% of the time and magnetic resonance imaging was correct on preoperative imaging 71% of the time. Two patients underwent preoperative ultrasound and their ultrasound reports did not accurately diagnose the presence of a ranula. Two patients underwent preoperative fine needle aspiration biopsy due to inconclusive preoperative imaging, in which results suggested either a ranula or epidermal cyst. Both ultimately did not match the final pathology. Three of eighteen patients (17%) underwent an inappropriate initial surgery due to incorrect imaging diagnoses and/or biopsy findings.

CONCLUSION

Despite use of preoperative modalities to distinguish plunging ranula from other cystic floor of mouth lesions, surgeons must be aware that no workup modality is fully precise. The potential for revision surgery must be included in all preoperative discussions for presumed plunging ranula.

LEVEL OF EVIDENCE

4 Laryngoscope, 134:2689-2696, 2024.

Ethanol Ablation of Ranulas and Risk Factor Analysis for Recurrence

Importance

Ethanol ablation (EA) was shown to be safe and effective for treating ranula, but few studies have assessed long-term outcomes and recurrence of ranula after EA.

Objective

To evaluate the long-term outcomes and the risk factors for recurrence and receipt of subsequent surgery in patients who underwent treatment with EA for ranula.

Design, Setting, and Participants

This case-series study was conducted at a single tertiary hospital and assessed patients who were treated with EA between July 2009 and March 2021. Among 70 consecutive patients, those with follow-up loss or who were followed up for less than 24 months were excluded.

Exposures

EA for ranula.

Main Outcomes and Measures

The primary outcome was recurrence at last follow-up after single or multiple EA sessions. Secondary outcomes included receipt of subsequent surgery and the recurrence-free survival (RFS) rate after initial EA. Factors possibly associated with outcomes included patient age and sex; ranula site, type, diameter, volume, and echogenicity; the presentation-to-EA interval; parapharyngeal space extension; and sublingual gland herniation. Risk factors were identified on logistic regression analyses. Two-year RFS rates were analyzed for the initial cohort using the Kaplan-Meier method and compared by log-rank tests.

Results

A total of 57 patients (mean [SD] age, 26.4 [12.1] years; 24 female individuals [42%]) who were followed up for a median of 57 months (range, 24-167 months) were included. The recurrence rate was 33% (n = 19), and 11 (19%) underwent subsequent surgery. Among patients with recurrence, 86% (31 of 36) experienced first recurrence within 12 months after initial EA. A presentation-to-EA interval of 12 months or longer was associated with an increased risk of recurrence (adjusted odds ratio [OR], 3.74; 95% CI, 1.01-13.82). No risk factors were significantly associated with subsequent surgery (highest OR in parapharyngeal space extension: adjusted OR, 4.96; 95% CI, 0.94-26.35). Among the initial cohort of 70 patients, 2-year RFS was lower in a maximum diameter of ranula of 5 cm or greater than less than 5 cm (24% [95% CI, 7%-41%] vs 50% [95% CI, 34%-66%]; difference, 26% [95% CI, -4% to 56%]; log-rank test, P = .02).

Conclusions and Relevance

This case-series study found that the recurrence rate of ranula after EA was 33%. A presentation-to-EA interval of 12 months or longer may be a risk factor for recurrence, suggesting that early intervention with EA might minimize recurrence. Most first recurrences occurred within 12 months after EA, with a maximum diameter of ranula of 5 cm or greater being a possible risk factor.

Surgical Management of Huge Ranula Resembling Double Tongue in Pediatric Patients: A Successful Treatment of Two Cases

Ranula is a fluid collection in a pseudo cystic wall secondary to the damage of the sublingual salivary gland causing blockage of salivary flow, leading to the extravasation phenomena. The growth rate of ranula varies depending on its severity. Due to its tendency to recur, the gold standard management of ranula has yet to be decided. The authors described two cases of young girls with huge ranulas on the floor of the mouth (FOM) resembling double tongue, which caused pain and discomfort during mastication. Following surgical excision of the ranulas along with the affected sublingual glands, both cases demonstrated successful treatment outcomes with no recurrence observed during post-operative follow-up. These cases highlight the importance of surgical excision of ranulas and removal of affected sublingual glands to prevent recurrence.

Recurrent Plunging Ranula Due to a Sublingual Ectopic Gland: A Rare Clinical Entity

Ranula is a benign cystic lesion caused by the escape and collection of salivary mucus. Classically, it is divided into simple ranulas, a cystic mass in the floor of the mouth, and diving/plunging/cervical ranulas, a submandibular mass without apparent intraoral involvement. Although plunging ranula is a well-documented cause of neck swelling, its association with the presence of ectopic sublingual glands is extremely rare, with less than five cases reported. Other cervical cystic lesions may have the same clinical aspect; therefore, advanced diagnostic techniques like a CT scan or MRI play a critical role in early diagnosis. Different approaches have been used to treat ranulas, including non-invasive, minimally invasive, and surgical techniques. The purpose of this paper is to highlight a case report of a giant plunging ranula due to an anatomical aberration of the right sublingual gland, along with a significant literature review.

Concurrent Perioperative Diagnosis of HIV in a Patient With Plunging Ranula: A Case Report

Oral manifestations may be the earliest indicators of HIV infection as it has strong association with oral candidiasis, hairy leukoplakia, linear gingival erythema, necrotizing ulcerative gingivitis, necrotizing ulcerative periodontitis, Kaposi sarcoma, and lymphoma. Other conditions such as diffuse infiltrative lymphocytosis syndrome, benign lymphoepithelial cyst, and salivary gland neoplasm have also been reported in HIV patients. Ranulas are caused by salivary leakage from the sublingual gland as a result of ductal obstruction or trauma. At the present time, there is no clear evidence of a link between plunging ranula and HIV. The authors described a case of plunging ranula of the right floor of the mouth with a concurrent perioperative diagnosis of HIV. Surgical excision of ranula and associated salivary glands via submandibular and intraoral approach was successfully done with no recurrence over a period of one year. This case also highlights the importance of taking a thorough clinical history from patients and always practicing universal precautions, especially during surgical interventions.

Amylase as a Diagnostic Tool for Plunging Ranula: Clinical Series and Description of the Technique

OBJECTIVES

This study describes a technique of measurement for neck cyst amylase content and reviews the experience of a tertiary referral center for cases of suspected plunging ranula.

METHODS

A retrospective study was performed at the Manukau Surgical Center in Auckland, New Zealand. Patients with a possible diagnosis of plunging ranula based on clinical presentation and diagnostic aspiration of the cyst contents were included. Demographic data, imaging and laboratory findings were collected, along with findings from surgery and histology. The technique for measuring the amylase of the aspirated cyst contents was also carefully recorded.

RESULTS

The 37 cases of confirmed plunging ranula included in this study had a submandibular cystic swelling that was aspirated. Imaging features consistent with a plunging ranula were seen in 89% of the study group. All cases had detectable levels of amylase of ≥3 U/L in the ranula contents. There was large variability (range: 5-560 U/L) in the concentration of amylase, with 70% of the cases demonstrating an amylase concentration below 200 U/L. Aspirates were typically described as viscous (87.5%) and yellow or straw-colored.

CONCLUSION

The combination of clinical presentation, imaging and the presence of amylase in the cyst contents is diagnostic for plunging ranula.

LEVEL OF EVIDENCE

4 Laryngoscope, 133:535-538, 2023.

New Conservative Approach for the Management of Recurrent Sublingual Ranula-A Case Report

Ranula is a rare and benign extravasation mucocele that is clinically characterized by asymptomatic sublingual or submandibular masses. Surgical excision is considered the most effective treatment approach, but it has been associated with high invasiveness and several complications (hemorrhage, damage to Wharton's duct, and lingual nerve injury). Over the past decade, more conservative therapies have been rapidly disseminated into clinical practice to seek a more effective and less traumatic approach for young patients. In this report, an 8-year-old female with an asymptomatic, recurrent sublingual ranula was treated using a conservative approach with marsupialization and an intracystic injection of a plaque remover (Hybenx^® gel). After incision of the cystic dome, Hybenx^® gel was applied into the cystic lumen for 20 seconds and then aspirated; next, the area was rinsed thoroughly with sterile saline solution before suturing. Ultrasound re-evaluation at 10 months and intraoral clinical examination at 24 months confirmed the absence of relapse. Our results support the hypothesis that marsupialization combined with intracystic injection of Hybenx^® gel could be an encouraging conservative treatment alternative for recurrent sublingual ranula in children. Further randomized controlled trials are needed to test this hypothesis.

Plunging Ranula Presenting as a Giant Anterior Cervical Cystic Mass: A Case Report and Literature Review

Plunging ranula, a subtype of ranula, commonly presents as a submandibular or submental cystic mass without oral counterpart, and its clinical management remains challenging. Herein, the authors report an extremely rare case of 30-year-old female patient with plunging ranula involving the root of the left anterior neck.

Surgical Treatment of Sublingual Gland Ranulas

Introduction Ranulas are divided into oral (OR) and plunging (PR) and comprise the most common pathology of the sublingual gland. This study presents a case series of patients operated due to OR and PR within different type of modalities in a 1-year period.

Objective The aim of this study is to determine the optimal surgical treatment of ranulas based on our results as well as in the literature review.

Methods The medical charts of 7 patients with sublingual gland ranulas treated in 2020 were reviewed.

Results The median age of the patients was 19. Three patients with OR were treated by marsupialization, micromarsupialization, and sublingual gland excision. Four patients with PR were operated via cervical approach in three cases and intraoral approach in one case. No recurrence was observed in 14 months of follow-up, on average.

Conclusion Micromarsupialization should be consider as the primary treatment for OR. In case of recurrent OR and primary or recurrent PR, the best results might be obtained by radical excision of the sublingual gland, which can be performed without resection of the ranula sac with the intraoral approach.

A case of sublingual ranula that successfully responded to micro-marsupialisation under COVID-19 infection: A case report

Ranula is a mucous retention cyst caused by the extravasation of mucus from the sublingual gland. We present a case of sublingual ranula that was successfully treated with micro-marsupialisation under COVID-19 infection. The patient was a 17-year-old Japanese male suffering from a sublingual ranula that did not improve after several rounds of puncture-aspiration therapy. The patient underwent OK-432 injection therapy under hospitalisation. However, the swelling worsened. Thus, micro-marsupialisation was subsequently performed. After micro-marsupialisation, the lesions flattened out, but 14 days after treatment, the patient was found to have asymptomatic COVID-19 infection when he underwent polymerase chain reaction testing as a close contact person. Simultaneously, the lesion re-swelled and became painful, so non-steroidal anti-inflammatory drugs were prescribed. The next day, the sutures spontaneously detached, viscous saliva and blood overflowed, and the ranula disappeared. Micro-marsupialisation is effective and useful even if the patient has a COVID-19 infection.

Transoral Complete vs Partial Excision of the Sublingual Gland for Plunging Ranula

OBJECTIVES

Plunging ranula is a pseudocyst of saliva extravasated from the sublingual gland (SLG) to the submandibular space. This is treated by transoral excision of the SLG or transcervical cyst excision that might differently affect surgical morbidity and recurrence. This study compared the clinical outcomes of complete vs partial excision of the SLG for plunging ranula.

STUDY DESIGN

A nonrandomized comparative study.

SETTING

Academic medical center.

METHODS

This study included 42 patients with plunging ranula who underwent complete or partial excision of the SLG with the evacuation of cystic content. Two surgical methods of complete or partial SLG resection were alternatively allocated to consecutive patients without randomization. The primary outcome was a postoperative recurrence. Secondary outcomes were operation time and complications.

RESULTS

Complete and partial excision of the SLG was performed in 22 and 20 patients, respectively, without injury to the Wharton's duct or the lingual nerve. Postoperative complications in 42 patients were minor with temporary events: hematoma, 1 (5%); tongue numbness, 2 (5%); dysgeusia, 4 (9%); and dysphagia, 2 (5%), which did not differ between patients with complete and partial excision of the SLG (P > .1). However, recurrence occurred in only 5 of 20 patients with partial SLG excision but none of 22 patients with complete SLG excision for a median follow-up of 36 months.

CONCLUSIONS

Complete SLG excision is preferred over partial SLG excision to treat plunging ranula for reducing postsurgical risks of complications and recurrence.

Sclerotherapy of ranulas with OK-432 - a prospective, randomized, double-blinded placebo-controlled study

BACKGROUND

Ranula is a rare benign cystic lesion in the floor of the mouth, which can herniate through the mylohyoid muscle and become a plunging ranula. Treatment for ranulas is currently surgical excision of the sublingual gland. Sclerotherapy with OK-432 is a well-established treatment of lymphatic malformations, but not yet thoroughly evaluated on ranulas. Objectives: To evaluate sclerotherapy of ranulas with OK-432 in a randomized double-blinded trial.

MATERIALS AND METHODS

20 patients with plunging or intraoral ranula were randomized to two double-blinded injections with OK-432 or saline. Effect on the ranula and evaluation of symptoms and QOL were investigated.

RESULTS

Treatment response differed significantly between OK-432 and placebo, p = .041(student's T-test). All patients with intraoral ranulas had a complete response, but only 1/4 of the patients with plunging ranula. The inflammatory reaction after injection with OK-432 caused a mild to moderate impact on QOL. No serious complications were observed.

CONCLUSION

This study suggests that sclerotherapy with OK-432 in ranula is a very effective treatment for intraoral ranulas, but possibly less useful in plunging ranulas.

SIGNIFICANCE

This is a limited study, but we believe that sclerotherapy with OK-432 should be recommended as primary treatment at least for intraoral ranulas.

Bleomycin sclerotherapy following doxycycline lavage in the treatment of ranulas: A retrospective analysis and review of the literature

OBJECTIVE

A ranula is a mucus-filled salivary pseudocyst that forms in the floor of the mouth, commonly arising from the sublingual or submandibular salivary glands following obstruction or trauma. Complete excision of the injured gland and removal of the cyst content is the first-choice therapy, but has the potential for complications related to injury to nearby structures. As such, minimally invasive approaches such as percutaneous sclerotherapy have been investigated. We aim to contribute to the literature by assessing the efficacy and safety of our technique through our experience with 18 patients over the last decade.

METHODS

This retrospective study evaluated 18 patients with intraoral and plunging ranulas treated by percutaneous bleomycin ablation. The primary endpoint was the treatment result. Secondary endpoints included bleomycin dosage and complications.

RESULTS

The study evaluated 12 males and six females with a median age of 23.5 years (range 13-39 years). At a final follow-up of at least 2 months (6.5±5.5 months), four patients demonstrated complete response (22%) and 14 patients demonstrated residual presence, recurrence, or regrowth of the lesion (78%). There were no statistically significant associations between outcomes and history of prior treatment, number of treatments, and size or type of ranula. No complications were noted.

CONCLUSIONS

Our findings indicate that bleomycin, while safe for use in various head and neck malformations, is of limited utility in ranula therapy when the offending gland is not addressed primarily.

The importance of sublingual gland removal in treatment of ranulas: A large retrospective study

PURPOSE

Investigate the efficacy of sublingual gland removal for the treatment of simple and plunging ranulas.

MATERIALS AND METHODS

After IRB approval, a retrospective review was performed on patients treated for a ranula from February 2013 to May 2018 at Texas Children's Hospital in Houston, TX. Clinical data was collected from medical records and patients were contacted in November 2018 to obtain additional information about recurrences or complications.

RESULTS

This study included 52 patients with ranulas (10 plunging, 42 simple; M:F 21:31) with a mean age of 9.68 years. Eighteen patients provided information in the extended follow-up period. Simple ranulas were treated with intraoral excision of the cyst and the sublingual gland (27 cases), marsupialization (7 cases), intraoral excision of the cyst alone (7 cases), and intraoral excision of the cystic component and subsequent marsupialization after recurrence (1 case); intraoral excision of the sublingual gland was not associated with any recurrence. Plunging ranulas were treated with intraoral excision of the cyst and/or sublingual gland (7 cases) or with a transcervical approach (3 cases). One patient was initially treated with sclerotherapy before undergoing intraoral excision of the sublingual gland. Two patients treated with transcervical excision of the cyst experienced recurrence compared to no recurrence with intraoral excision of the sublingual gland.

CONCLUSION

Intraoral removal of the sublingual gland is the most effective treatment for both simple and plunging ranulas. Plunging ranulas must be considered in patients presenting with a submandibular and submental cystic mass given intraoral extension may not be apparent.

The anatomical basis and rational for the transoral approach during the surgical excision of the sublingual salivary gland for the management of plunging ranula

PURPOSE

The aim of this study was to illustrate and confirm that the complete intraoral excision of the sublingual gland alone, is anatomically the most rational approach, for the management of plunging ranula.

MATERIAL AND METHODS

We retrospectively reviewed clinical charts of diagnosed HIV-infected patients presenting with plunging ranula. The intraoral approach was used for the complete excision of the sublingual gland with evacuation of the pseudocystic content only. Neither extra oral approach, nor ranula dissection / drainage was performed. The surgical procedure was performed using local anesthesia. Pre- and postoperative MRI-scan investigations were recorded. Histological reports were documented to confirm the diagnosis of oral mucocele. Patients were clinically monitored.

RESULTS

We identified 90 adults presenting with oral mucocele, type ranula. Seventy (77%) of them were diagnosed with HIV infection. Plunging ranula was recorded in 35 (50%) patients from the latter group. The study enrolled 11 operated patients whose files contained useable data, including an acceptable follow-up period. The postoperative follow-up period ranged from three to 15 months. The clinical and postoperative MRI-scans of operated patients demonstrated satisfactory results. There were neither postoperative complications nor recurrence of ranula reported.

CONCLUSION

The location of the sublingual gland in the floor of the mouth coupled with the physio-pathogenesis of the plunging ranula, makes the transoral complete excision of the offending gland, with the intraoral evacuation of the pseudocyst, anatomically the most rational approach for plunging ranula management. There is no need for cervical approach, ranula dissection and/or postoperative placement of drainage.

Case report of the management of the ranula

Ranula is a mucocele caused by extravasation of the sublingual gland on the floor of the mouth. The most common presentation is a cystic mass in the floor of the mouth. A portion of the sublingual gland could herniate through the mylohyoid muscle, and its extravasated mucin can spread along this hiatus into submandibular and submental spaces and cause cervical swelling. This phenomenon is called plunging ranula. A variety of treatments for ranula has been suggested and include aspiration of cystic fluid, sclerotherapy, marsupialization, incision and drainage, ranula excision only, and excision of the sublingual gland with or without ranula. Those various treatments have shown diverse results. Most surgeons agree that removal of the sublingual gland is necessary in oral and plunging ranula. Four patients with ranula were investigated retrospectively, and treatment methods based on literature review were attempted.

Plunging ranula with lingual nerve tether: Case report and literature review

Plunging ranulas are most often treated surgically; various surgical approaches may be necessary depending on the unique characteristics of each case. Here, we present the case of a plunging ranula noted on imaging to have a cordlike tether, which was revealed intraoperatively to be the lingual nerve. This case illustrates the importance of preoperative imaging for surgical planning, and when a transcervical approach may be the best choice for plunging ranulas.

Acute presentation of an intraoral dermoid cyst causing airway compromise in a young child

A 4-month-old boy presented with a cystic swelling at the floor of the mouth causing acute airway compromise. The only previous history of note, was a tongue tie release at 3 days old. CT scan suggested a dermoid cyst with extensive floor of mouth abscess. He had an excision of the cyst and drainage of the superimposed abscess and made a good recovery. The histology report revealed a dermoid cyst which is a rare diagnosis in a child, particularly within the oral cavity. Early treatment is required to remove these lesions especially when they cause airway compromise or swallowing difficulties. This is the first case to our knowledge which suggests tongue tie release procedures causes a predisposition to the development of dermoid cysts in the oral cavity.

Sublingual gland excision for the surgical management of plunging ranula

OBJECTIVE

A plunging ranula is a pseudocystic collection of mucin extravasated from the sublingual gland into the floor of mouth and through the mylohyoid muscle into the neck. While the lining of a ranula is non-secreting and resection of the sublingual gland is adequate for simple sublingual mucoceles, many surgeons attempt to address plunging ranulas with extensive transoral and transcervical dissections. We review our experience managing plunging ranulas with intraoral sublingual gland excision and ranula drainage alone.

METHODS

This is a case series of patients with plunging ranulas who underwent transoral sublingual gland excision and ranula drainage in the past 10 years at the Massachusetts Eye and Ear. All ranulas were confirmed by radiographic imaging. Data were gathered from the medical record and telephone surveys.

RESULTS

Twenty-one patients with 22 distinct ranulas underwent this surgical approach. Average ranula size on imaging was 4.3 cm (SD = 1.3). Thirteen patients with 14 ranulas were followed up for greater than 6 months while the remaining 7 patients were lost to follow-up. Median follow-up for the 13 patients was 30 months (range 6 to 80). One ranula recurred requiring excision of residual sublingual gland (7%). One patient developed a local infection that was treated with antibiotics (7%). No long term complications were reported.

CONCLUSION

Simple transoral excision of the sublingual gland with ranula drainage is sufficient for treatment of plunging ranulas. It is essential to obtain a full resection of the gland to prevent relapse. This limited approach has low rates of complications and ranula recurrence.

Modern management of paediatric obstructive salivary disorders: long-term clinical experience

Recent technological improvements in head and neck field have changed diagnostic and therapeutic strategies for salivary disorders. Diagnosis is now based on colour Doppler ultrasonography (US), magnetic resonance (MR) sialography and cone beam 3D computed tomography (CT), and extra- and intracorporeal lithotripsy, interventional sialendscopy and sialendoscopy-assisted surgery are used as minimally invasive, conservative procedures for functional preservation of the affected gland. We evaluated the results of our long-term experience in the management of paediatric obstructive salivary disorders. The study involved a consecutive series of 66 children (38 females) whose obstructive salivary symptoms caused by juvenile recurrent parotitis (JRP) (n = 32), stones (n = 20), ranula (n = 9) and ductal stenosis (n = 5). 45 patients underwent interventional sialendoscopy for JRP, stones and stenoses, 12 a cycle of extracorporeal shockwave lithotripsy (ESWL), three sialendoscopy-assisted transoral surgery, one drainage, six marsupialisation, and two suturing of a ranula. Three children underwent combined ESWL and interventional sialendoscopy, and seven a secondary procedure. An overall successful result was obtained in 90.9% of cases. None of the patients underwent traditional invasive sialadenectomy notwithstanding persistence of mild obstructive symptoms in six patients. No major complications were observed. Using a diagnostic work-up based on colour Doppler US, MR sialography and cone beam 3D TC, children with obstructive salivary disorders can be effectively treated in a modern minimally-invasive manner by extracorporeal and intracorporeal lithotripsy, interventional sialendoscopy and sialendoscopy-assisted transoral surgery; this approach guarantees a successful result in most patients, thus avoiding the need for invasive sialadenectomy while functionally preserving the gland.

Plunging Ranula in a 78- year- old Male - a Rare Case Report

The term Ranula is a Latin word meaning frog. It refers to a bluish translucent cystic lesion in the floor of the mouth resembling the underbelly of a frog. Ranulas can be true cysts occurring due to ductal obstruction of the sublingual gland or a minor salivary gland or a pseudocyst as a result of ductal injury leading to extravasation and accumulation of saliva in the surrounding tissues. Clinically ranulas present as intraoral or plunging ranulas. The prevalence of ranula is 0.2% per 1000 patients Ranulas account for 6% of all salivary gland cysts. Ranulas are more common in children and young adults. However the plunging type occurs most commonly in the later third decade. The diagnosis of plunging ranula is based on a combined clinical,radiographic imaging and histologic findings. The treatment of ranulas have always been controversial.The treatment modalities range from simple marsupialisation to excision of the pseudocyst along with sublingual or submandibular gland excision.The purpose of this paper is to present a rare case of plunging ranula and to highlight the importance of considering plunging ranula in the differential diagnosis of lesions of the neck.

Key words:Plunging Ranula,mucus, submandibular gland, transcervical approach.

Plunging Ranula: A Case Report

A plunging or diving ranula is a rare mucous fluid collection in the submandibular or parapharyngeal space resulting from damage or rupture of one or more ducts of the sublingual gland. The most common clinical presentation is a painless, slow-growing, pliable mass in the floor of the mouth, sometimes extending below the mandible through a defect in the mylohyoid muscle. This case report presents a young female patient who was suspected of having a plunging ranula. This case also highlights the role that sonography and other diagnostic tools play in the evaluation of this phenomenon.

A 17-year surgical experience of the intraoral approach for ranulas

INTRODUCTION

The aim of this study was to analyze the clinical features and treatment outcomes in order to determine the optimal management of ranulas in our Oral and Maxillofacial Surgery department with long-term results.

PATIENTS AND METHODS

A retrospective study was performed to evaluate patients with a final diagnosis of a simple or plunging ranula at Lille Teaching Hospital from May 2000 to January 2017. Clinical data on ranulas that were reviewed included gender, age, symptoms, location of the lesion, surgical procedures, complications, recurrence and follow-up.

RESULTS

The 26 patients included in the study comprised 18 males and 8 females, ranging from 3-months to 38 years of age. A total of 27 ranulas were managed: 25 oral ranula and 2 plunging ranulas. Twelve patients had undergone marsupialization (44.4%), 7 patients had complete excisions of the ranula (25.9%) or partial excisions combined with marsupialization (14.8%) and 4 patients (14.8%) had undergone excision of the sublingual gland (SLG). Seven ranulas recurred (25.9%). Not a single case recurred following the excision of the SLG. Treatments that included marsupialization were associated with the lowest recurrence rate (16.7%) after SLG excision, followed by combined marsupialization and ranula excision (25%) and by ranula excision alone (57%). There were no major complications.

DISCUSSION

Long-term outcomes confirm the different surgical procedures available in the outpatient clinic for the management of ranulas based on our surgical experience. Transoral resection of the SLG should be the optimal treatment, producing the lowest recurrence rate.

Treatment of intraoral ranulas with a two-incision fistula technique: the management of recurrence

The two-incision fistula technique for the treatment of oral ranulas has recently been introduced to clinical practice. We reviewed 52 patients who had recurrences after this treatment, and explored the possible causes and underlying mechanisms. A total of 13/53 ranulas had recurred, so we repeated the operation, and one patient had the ranula and the sublingual gland resected. We found that the thin mucous membrane cracked at the double incisions, which led to the formation of a fistula and promoted the drainage of cystic fluid. The results indicated that the recurrence of ranulas after the two-incision fistula technique can be reduced further. To avoid recurrence, the technique should be adjusted slightly, depending on the type of ranula present.

Ranula: Current Concept of Pathophysiologic Basis and Surgical Management Options

Background

There is no consensus opinion on a definitive surgical management option for ranulas to curtail recurrence, largely from the existing gap in knowledge on the pathophysiologic basis.

Aim

To highlight the current scientific basis of ranula development that informed the preferred surgical approach.

Design

Retrospective cohort study.

Setting

Public Tertiary Academic Health Institution.

Method

A 7-year 7-month study of ranulas surgically managed at our tertiary health institution was undertaken—June 1, 2008–December 31, 2015—from case files retrieved utilising the ICD-10 version 10 standard codes.

Results

Twelve cases, representing 0.4 and 1.2% of all institutional and ENT operations, respectively, were managed for ranulas with a M:F = 1:1. The ages ranged from 5/12 to 39 years, mean = 18.5 years, and the disease was prevalent in the third decade of life. Main presentation in the under-fives was related to airway and feeding compromise, while in adults, cosmetic facial appearance. Ranulas in adults were plunging (n = 8, 58.3%), left-sided save one with M:F = 2:1. All were unilateral with R:L = 1:2. Treatment included aspiration (n = 2, 16.7%) with 100% recurrence, intra-/extraoral excision of ranula only (n = 4, 33.3%) with recurrence rate of 50% (n = 2, 16.7%), while marsupialisation in children (n = 1, 8.3%) had no recurrence. Similarly, transcervical approach (n = 5, 41.7%) with excision of both the ranula/sublingual salivary gland recorded zero recurrence. Recurrence was the main complication (n = 4, 33.3%).

Conclusion

With the current knowledge on the pathophysiologic basis, extirpation of both the sublingual salivary gland and the ranula by a specialist surgeon is key for a successful outcome.

Plunging ranula - patient characteristics, treatment, and comparison between different populations

OBJECTIVES

To review our clinical experience and characteristics of Finnish patients with plunging ranula and compare our results with reports from other populations.

DESIGN

A retrospective study from the electronic hospital records between 2005 and 2016.

SETTING

The Department of Otorhinolaryngology and Head and Neck Surgery of Helsinki University Hospital, Finland.

RESULTS

We describe the characteristics and treatment of 41 patients with MRI-confirmed plunging ranula. Most of our patients were young adults and 88% of them were male. Surgery and sclerotherapy were used for treatment.

CONCLUSIONS

The vast majority of Finnish plunging ranula patients in our cohort were male, suggesting significant population-related differences in plunging ranula gender distribution. Transoral surgery seemed to result in lowest recurrence rate and was the most common treatment in our clinic.

Ethanol Ablation of Ranulas: Short-Term Follow-Up Results and Clinicoradiologic Factors for Successful Outcome

BACKGROUND AND PURPOSE

Surgical excision of an affected sublingual gland for treatment of a ranula can carry a potential of a nerve damage or postoperative complications. However, there have been little studies about effective minimally invasive therapeutic method, yet. Our aim was to evaluate the efficacy and safety of ethanol ablation of ranulas and the clinicoradiologic factors that can predict outcome.

MATERIALS AND METHODS

This retrospective study evaluated 23 patients with ranulas treated by percutaneous ethanol ablation. Treatment outcome was assessed in 20 patients followed for at least 6 months. The duration of symptoms before ethanol ablation, pretreatment volume, and parapharyngeal extension on sonography and/or CT were correlated with the outcome. The Mann-Whitney U test and Fisher exact test were used for comparison of the factors according to the outcome.

RESULTS

The study evaluated 14 males and 9 females with a median age of 26 years (range, 3-41 years). Among 20 patients who were followed for at least 6 months (median, 20 months; range, 6-73 months), 9 patients (45%) demonstrated complete disappearance of the ranulas and 11 (55%) showed an incomplete response. When the patients were divided according to the duration of symptoms before ethanol ablation, the complete response rate was significantly higher in patients with ≤12 months of symptoms (73%, 8/11) than that in others (11%, 1/9) (P = .010). Pretreatment volume and parapharyngeal extension were not significantly different between the 2 groups.

CONCLUSIONS

Ethanol ablation is a safe and noninvasive treatment technique for ranulas with a significantly better outcome in patients with ≤12 months of symptoms. Therefore, it could be considered an alternative nonsurgical approach for ranulas with recent onset of symptoms.

Excision of sublingual gland as treatment for ranulas in pediatric patients

OBJECTIVE

The aim of this case study is to demonstrate that post-operative complication rates of sublingual gland excision for treatment of ranulas are equal to or less than alternative methods with a lower recurrence rate than other surgical methods.

METHODS

This was a retrospective review of pediatric patients from 2004 to 2015 at Children's Hospitals and Clinics of Minnesota. Sixteen ranulas and 6 plunging ranulas were treated via sublingual gland excision during this time frame. Data examined included age, gender, scans of the lesion, location and size of lesion, surgical procedures, complications, and recurrence.

RESULTS

There were 22 patients who met criteria. Only one patient had recurrence of the lesion (4.5%). One patient reported lateral tongue numbness post-operatively, and one patient had a hypoglossal nerve injury, with tongue deviation upon exam. Both of these complications were temporary and resolved within months of the procedure.

CONCLUSION

Although sublingual gland excision is a definitive treatment for ranulas, many surgeons still utilize other methods such as marsupialization, drainage of the cyst, or excision of ranula alone as the primary method of treatment due to concerns about complications. This retrospective study demonstrates that excision of the sublingual gland is both a safe and effective method of treatment for ranulas.

[Congenital mucocele of the ventral face of the tongue]

BACKGROUND

Congenital cystic lesions of the oral cavity are an extremely rare occurrence. Their prenatal diagnosis is essential since they can impede respiratory and swallowing functions. We describe a case that was detected prenatally and discuss its management.

CASE REPORT

A 21-year-old primigravida patient who was 23 weeks pregnant was referred to our obstetrics and gynecology center after fetal ultrasonography showed a cystic lesion of the oral cavity. She had no family history of any congenital anomalies. Ultrasonography showed a male fetus with an anechoic mass measuring 21×11 mm encompassing the entire oral cavity, evoking either a mucocele or a cystic hygroma. Magnetic resonance imaging (MRI) showed a fetus with a wide-open mouth, due to a well-demarcated protruding cystic mass with no solid component, suggestive of a mucocele. A prenatal sonographically guided percutaneous needle aspiration of mucous fluid was performed at 33 gestational weeks. Although the mucocele decreased significantly in size, it nevertheless continued to expand progressively. After an uncomplicated pregnancy, the patient had spontaneous onset of labor at 39 weeks of gestation. An iterative aspiration was performed in the same manner in utero, resulting in a complete collapse of the mucocele. If needed, intubation could be considered. A 3030-g male was born by vaginal delivery, without respiratory distress. Clinical examination showed the extremely opened mouth and confirmed the presence of a large cystic mass approximately 4 cm in diameter, of sublingual origin and encompassing the entire oral cavity. The continuous protrusion of the tongue was responsible for the infant's inability to close the mouth and be breastfed. After insertion of a feeding tube, the newborn had maxillofacial surgery consisting in marsupialization of the cyst at 2 days of age. The mucocele decreased in size and the postoperative course was uneventful. No recurrence was observed at 6 months' follow-up.

DISCUSSION AND CONCLUSION

Congenital mucoceles of the tongue are very rare benign lesions of the oral cavity, resulting from extravasation or retention of mucus from minor salivary glands. Their prevalence is unknown and, to our knowledge, less than ten cases of prenatal diagnosis have been previously reported. Such cystic lesions can cause respiratory distress and swallowing disorders in newborns. They are usually suspected on ultrasonography. MRI highlights the nature of the lesion and its locoregional connections with muscles and blood vessels. It provides a good analysis of the soft tissues and can distinguish between the muscles of the tongue and the pathologic mass. However, the use of CT has been reported when the diagnosis was made after childbirth or in adulthood. Given the risks of interference of the lesion with respiratory and swallowing functions, intrauterine decompression of the mucocele can be an option to prevent respiratory distress at birth and the need for neonatal intubation. Mucoceles provide somewhat confusing and disturbing ultrasonographic appearances, which can be stressful for the medical team and parents. Prenatal diagnosis and early surgical intervention (marsupialization, complete excision of the cyst or the salivary gland) can prevent risks of breathing distress and breastfeeding problems. Therefore, this strategy is essential to offer fast and satisfactory management of this rare but anxiety-producing congenital situation.

[Plunging ranula. Review]

INTRODUCTION

Ranula is a pseudocyst of the sublingual gland, often of unknown etiology. In few cases, it can extend to the neck when passing through the mylohyoid muscle. Diagnosis is not always easy as other cervical cystic lesions may have the same clinical aspect. Some ranulas recur after removal. The aim of our study was to conduct a review about plunging ranulas, with a focus on the most useful paraclinical exams and the most effective treatment.

MATERIAL AND METHODS

A review of the literature has been conducted in the PubMed database between 2015 and 2010 using following keywords: plunging ranula, recurrent plunging ranula.

RESULTS

Thirteen articles reporting 37 cases of plunging ranulas have been selected. Among these cases, 3 recurred. Paraclinical exams consisted in US, CT scan and MRI. Main reported treatment was sublingual gland removal, sometime associated with marsupialization.

DISCUSSION

The most useful paraclinical exam is CT scan. Total sublingual gland removal is the most efficient treatment.

Clinical evaluation of a two-incision fistula technique for the treatment of oral ranulas

Oral ranulas are caused by extravasation of mucus from the sublingual glands, and the preferred treatment varies. We have developed a two-incision fistula operation for their treatment, and in this clinical study we have evaluated the efficacy and safety of this approach. Twelve patients with oral ranulas confirmed by fine needle aspiration cytology were enrolled and gave their consent to be treated by our new technique. The clinical outcomes and complications were evaluated during a period that ranged from 8-24 months. Nine ranulas became smaller and gradually disappeared, and there were no complications or injury to Wharton's duct. Three ranulas recurred, but disappeared after a second operation. The two-incision fistula operation can be effective and safe as an initial treatment for oral ranulas, and the method may become the preferred management for retention cysts.