Surgery for plunging ranula: the lesson not yet learned?

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.

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.

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.

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.

Extracardiac Rhabdomyoma Mimicking Plunging Ranula

Histopathologically adult extracardiac rhabdomyoma is a benign tumour of mature striated muscle. It is a slow- growing tumour with predilection to occur in head and neck region. They appear mainly as a solitary lesion, and about 15% of them can be multicentric. A 56-year-old man presented to us with the floor of mouth swelling persisted for one year and the right neck swelling for three years mimicking a plunging ranula. Radiological imaging revealed enhancing mass at the floor of mouth and submandibular region. The mass represented a nonvascular benign tumour. Subsequently, the patient underwent excision of the mass via transcervical and transoral method. Histopathological examination revealed adult type of extracardiac rhabdomyoma. Adult type of extracardiac rhabdomyoma should be considered in the differential diagnosis for the head and neck masses. A complete excision will reduce the risk of recurrence.

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.

Bilateral Plunging Ranulas in South Auckland: Evidence for a Genetic Basis

OBJECTIVES

We present a series of bilateral plunging ranula patients to examine the etiology, diagnosis, treatment, and prognosis of this condition.

METHODS

A retrospective chart review was performed on all cases of plunging ranula treated at the Department of Otolaryngology-Head and Neck Surgery, Counties Manukau District Health Board, New Zealand, between 2001 and 2019.

RESULTS

There were 17 patients with bilateral plunging ranulas from a total of 187 plunging ranula patients. Eight patients were of Pacific Island descent; six were Maori; and three were Asian. There were no European patients with bilateral plunging ranulas. There were three types of bilateral plunging ranula patients: 1) Metachronous plunging ranulas-Five patients presented with a unilateral plunging ranula with no evidence of a contralateral plunging ranula on initial imaging. Despite negative contralateral imaging findings, these patients developed a clinically evident contralateral plunging ranula 21 to 61 months later. 2) Synchronous plunging ranulas detected on imaging-Eight patients presented with a clinically evident unilateral plunging ranula but also had a contralateral plunging ranula detected on imaging. 3) Clinically evident synchronous plunging ranulas-Four patients presented with bilateral clinically evident plunging ranulas, which were also evident on imaging. Twelve patients underwent bilateral transoral sublingual gland excision and plunging ranula evacuation.

CONCLUSION

All patients with a unilateral plunging ranula should be advised of the potential for developing contralateral disease, and this should be emphasized in patients of Pacific Island, Maori, and Asian descent.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:73-77, 2021.

Plunging Ranulas and Prevalence of the "Tail Sign" in 126 Consecutive Cases

OBJECTIVES

Plunging (or diving) ranulas are extravasation pseudocysts arising from the sublingual gland that present as soft submandibular swelling. The "tail sign" has been widely reported as pathognomonic for their diagnosis. It is described as a smooth tapering comet-shaped unilocular fluid mass with its "tail" in the collapsed sublingual space (SLS) and its "head" in the posterior submandibular space. This sign is based on the premise that extravasated saliva from the sublingual gland in the SLS escapes and plunges, over the posterior edge of the mylohyoid muscle into the submandibular space. Therefore, some fluid must be present in the posterior SLS in almost all patients with plunging ranulas. This study aimed to determine the frequency of fluid seen with ultrasound (US) in the posterior SLS to corroborate the tail sign.

METHODS

A total of 126 consecutive cases of surgically proven plunging ranulas were investigated with US over 13 years. The findings were reviewed retrospectively for the prevalence of fluid in the posterior SLS.

RESULTS

Thirteen patients (10.3%) showed SLS fluid on US images. Most showed fluid extension through a mylohyoid dehiscence. Only 2 patients (1.6%) showed fluid within the posterior SLS, and 1 patient alone in this entire study showed all of the components of the classically described tail sign.

CONCLUSIONS

This largest ever radiologic study showed low prevalence of the tail sign in 2 of 126 patients. A mylohyoid dehiscence was the more common route for extravasation. Absence of the tail sign does not exclude the diagnosis of a plunging ranula.

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.

Percutaneous treatment of ranulas: ultrasound-guided drainage with salivary gland chemical ablation

BACKGROUND

Ranulas are salivary pseudocysts in the floor of the mouth adjacent to damaged salivary glands. Current surgical management is drainage of the ranula with removal of the offending gland. An analogous percutaneous procedure could potentially offer similar treatment efficacy in a more minimally invasive way.

OBJECTIVE

To evaluate the outcomes of a cohort of patients with ranulas treated with percutaneous ranula aspiration and chemical ablation of the source salivary gland to see whether this technique could be proposed as a minimally invasive treatment alternative.

MATERIALS AND METHODS

This retrospective single-center study evaluated 24 patients treated percutaneously for ranulas between January 2004 and December 2014. All patients were treated with percutaneous ranula aspiration and chemical ablation of the offending salivary gland. Treatment success and any complications were recorded.

RESULTS

Complete ranula eradication was successfully accomplished in 87.5% of the patients with no complications.

CONCLUSION

Initial results suggest that our technique of percutaneous aspiration of ranulas and chemical ablation of the source salivary gland is safe and effective.

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.

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.

Surgical management of plunging ranulas: a 10-year case series in South East Queensland

BACKGROUND

Plunging ranulas are rare mucous extravasation pseudocysts that arise in the floor of the mouth and pass into the submandibular space of the neck. The aim of this study was to investigate the diagnosis, surgical management and outcomes of patients with a plunging ranula at our institution in South East Queensland over a 10-year period.

METHODS

A retrospective analysis of adult patients diagnosed with and treated for plunging ranula between 2006 and 2016 at Logan Hospital was conducted. Patient demographics, preoperative investigations, surgical management and post-operative outcomes were collected from medical records.

RESULTS

A total of 18 adult patients were treated for plunging ranula. Of the 18 cases, 17 were treated via transoral excision of the sublingual gland. The mean age at presentation was 28.8 years with a 3:1 female to male predominance. Fifty-six percent of patients were of Polynesian descent. The success rate was 94% with only one patient experiencing recurrence and requiring re-excision of remnant sublingual gland tissue. Three patients (17%) developed complications related to post-operative bleeding. There was a slight predominance for right-sided disease (56%) compared with left and one case of bilateral plunging ranulas in this series.

CONCLUSION

This study demonstrates that excision of the sublingual gland is an effective and safe treatment for plunging ranula. The majority of plunging ranulas occur in patients aged <30 years with a higher incidence in patients of Polynesian heritage, which is consistent with previous studies suggesting a possible underlying genetic predisposition for this condition.

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.

The epidemiology of plunging ranula in South Auckland

OBJECTIVES/HYPOTHESIS

Estimate the incidence rate and provide basic descriptive epidemiologic characteristics of plunging ranulas in a multi-ethnic population.

STUDY DESIGN

Case series with chart review.

METHODS

The study group comprised all Counties Manukau Health (CMH, Manukau City, Auckland, New Zealand) patients presenting to the CMH Department of Otolaryngology with a diagnosis of plunging ranula from January 2001 to December 2013, as recorded in the departmental case register. Non-CMH domicile patients were excluded. South Auckland comprised the base population, as serviced by CMH. The 2006 New Zealand census data was used for population demographics.

RESULTS

A total of 134 cases of plunging ranula were identified. The overall annual crude incidence rate was 2.4 per 100,000 person-years. The gender specific incidence rate for males was 3.2 per 100,000 (95% confidence interval [CI]: 2.5. 3.9) and for females was 2.0 per 100,000 (95% CI: 1.5, 2.6). The overall age-adjusted annual incidence rate was 2.6 per 100,000 (95% CI: 2.1, 3.0). The age-adjusted incidence was highest among Maori (6.7 per 100,000, 95% CI 4.9, 8.4), followed by Pacific Island (4.4 per 100,000, 95% CI 3.2, 5.6), Asian (0.7 per 100,000, 95% CI 0.2, 1.2), and European population (0.6 per 100,000, 95% CI 0.3, 0.8).

CONCLUSION

We have quantified for the first time the age-specific and age-adjusted incidence rates for plunging ranula by gender and ethnicity. The results show a likely underlying genetic predisposition for this condition, possibly with a superimposed environmental acquired factor relating to external, minor blunt trauma to the neck.

LEVEL OF EVIDENCE

4. Laryngoscope, 126:2739-2743, 2016.

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.

Submental epidermoid cysts in children

Epidermoid cysts are lesions, which form as a result of implantation of the epidermis in the layers of the dermis or the mucous membrane. The lesions are rare in adults with 7% occurring in the head and neck area and most often located in the submental region. In children population submental epidermoid cysts are extremely rare. The differential diagnosis of the lesions is necessary as it affects the choice of treatment methods. Among the pathological conditions occurring in that region, salivary retention cyst (ranula), thyroglossal duct cyst, vascular lymphatic malformation (cystic hygroma), median neck cyst, lymphadenopathy, thyroid gland tumor, laryngeal cyst, epidermoid and dermoid cysts, submental abscess, sialolithiasis and salivary gland inflammation should be considered. The authors of the present report demonstrate two cases of submental epidermoid cysts in children. Differential diagnosis in case of suspected submental epidermoid cyst in a child with proposed clinical practice and literature review is provided.

Types of sublingual gland herniation observed during sonography of plunging ranulas

OBJECTIVES

Plunging ranulas have been shown to have a common trio of mylohyoid defects, sublingual gland herniation, and submandibular space fluid collections. The herniated sublingual gland may be susceptible to subclinical trauma. The purpose of this study was to investigate the frequency of occurrence of various types of active sublingual gland herniation observed during diagnostic sonographic studies.

METHODS

Sonographic findings of sublingual gland herniation from 76 patients with a total of 80 plunging ranulas are presented. All sublingual gland herniations, including those on the contralateral side, were documented at the time of the examinations and reviewed later. The sonographic appearances of active sublingual gland herniation were given the names "slide," "wobble," "mushroom," and "retrusion" to reflect the observed movement.

RESULTS

Mylohyoid defects were found in 98% of plunging ranulas. The different types of sublingual gland herniation observed were as follows: slide in 77.8%, wobble in 11.1%, mushroom in 9.7%, and retrusion in 1.4%. The unaffected contralateral side showed a wobble in 44.8% of cases and slide in 8.9%.

CONCLUSIONS

Sublingual gland herniation through mylohyoid defects is easily missed if one is unaware. Prior knowledge of the various types of sublingual gland herniation and their frequencies of occurrence are very helpful during diagnostic sonographic examinations.

Evaluation of alpha-fetoprotein staging system for hepatocellular carcinoma in noncirrhotic patients

The Barcelona Clinic Liver Cancer (BCLC) staging classification is commonly used for staging hepatocellular carcinoma (HCC). This system assumes the coexistence of cirrhosis; however, a significant proportion of patients with HCC present without cirrhosis. Recently, an alternative system was proposed that stratifies patients according to alpha-fetoprotein (AFP) level. The aim of this study was to apply the AFP staging system to noncirrhotic patients with HCC and evaluate its ability to predict overall survival (OS). A prospective hepatopancreatobiliary database was reviewed for all patients with a diagnosis of HCC. Patients were staged based on BCLC classification as well as by AFP stage according to four levels: less than 10 ng/mL, 10 to 150 ng/mL, 150 to 500 ng/mL, and greater than 500 ng/mL. Cirrhotic patients were compared with noncirrhotic patients in terms of patient demographics and HCC stage. Kaplan-Meier (KM) analysis of OS was performed for noncirrhotic patients according to BCLC and AFP staging systems. Cirrhotic and noncirrhotic patients differed significantly in terms of median age at presentation (64 vs 70 years, P < 0.001) and gender (76 vs 65% male, P = 0.006). BCLS staging classification did not distinguish between cirrhotics and noncirrhotics (P = 0.733), whereas AFP staging demonstrated a significant difference between the two groups (P < 0.0001). KM analysis of OS for noncirrhotic patients with HCC was significant for both the BCLC and the AFP staging systems (P = 0.003 vs P < 0.0001, respectively). Patients presenting with HCC in the absence of cirrhosis appear to have different characteristics than patients with cirrhosis. Staging according to AFP level is an appropriate predictor of prognosis in noncirrhotic patients with HCC.

Imaging of pediatric floor of mouth lesions

There is a vast spectrum of pathology that afflicts the floor of mouth in children. These span inflammatory conditions, vascular malformations, developmental anomalies, benign tumors and malignancies. While this area is readily evaluated on clinical exam, imaging is often performed to better characterize the disorder prior to management. The imaging modalities most frequently utilized are US, CT and MR. The purpose of this article is to describe the primary conditions that occur in this location in children so that radiologists may provide an appropriate differential diagnosis. These include ranula, venolymphatic malformation, dermoid, teratoma, foregut duplication cyst, hairy polyp, thyroglossal duct cyst and rhabdomyosarcoma. For each pathological condition, there will be a focus on describing its imaging manifestation. Floor of mouth anatomy, imaging approach during both prenatal and postnatal life and etiologies will be discussed. Surgical considerations and operative photographs will also be presented.

Postmortem investigation of mylohyoid hiatus and hernia: aetiological factors of plunging ranula

The mylohyoid hiatus and hernia were discovered in the nineteenth century and were considered to explain the origin of the plunging ranula from the sublingual gland. This formed the rationale for sublingual sialadenectomy for the treatment of plunging ranula. However, a more recent, extensive histological investigation reported that hernias contained submandibular gland, which supported an origin of the plunging ranula from the submandibular gland and submandibular sialadenectomy for the treatment of plunging ranula. We therefore decided to investigate the occurrence and location of the hiatus and the histological nature of the hernia. Twenty-three adult cadavers were dissected in the submandibular region. The locations and dimensions of mylohyoid hiatuses were measured before taking biopsies of hernias. Hiatuses with associated hernias were found in ten cadavers: unilateral in six; and bilateral in four, in one of which there were three hiatuses. Sublingual gland was identified in nine hernias and fat without gland in six. This investigation supports clinical and experimental evidence that the plunging ranula originates from the sublingual gland and may enter the neck through the mylohyoid muscle. It confirms the rationale of sublingual sialadenectomy for the treatment of plunging ranula.

Management of ranula: 9 years' clinical experience in pediatric and adult patients

PURPOSE

The aim of the present study was to evaluate the long-term results in the authors' department in the management of patients with oral and plunging ranulas. A specific diagnostic and therapeutic approach is suggested based on these data and data from the literature.

MATERIALS AND METHODS

A retrospective analysis of 65 patients with a final diagnosis of ranula was carried out. The medical records were evaluated for the principal demographic, clinical, diagnostic, and therapeutic data. Statistical analysis was used to compare outcomes of the different treatments.

RESULTS

Treatments that included complete sublingual gland excision were associated with the lowest recurrence rate (3.6%), followed by partial sublingual gland excision (9.1%), marsupialization (13%), and ranula excision (36.7%). Nine patients (13.8%) had recurrences. A statistically significant difference was observed (P = .01) in the recurrence rate between complete sublingual gland excision and ranula excision alone. Complications developed in 7 patients (10.8%). Ultrasonography performed in all patients showed an intimate relation among the cyst, mylohyoid muscle, and sublingual gland. Dehiscence of the mylohyoid muscle was noted in some cases.

CONCLUSIONS

The surgical experience in the authors' department confirms the different treatments that are offered for ranula. Sublingual gland excision should be the preferred treatment, but marsupialization may be useful as an alternative minimally invasive procedure, with a success rate higher than 85% and no risk of increased complications if revision surgery is needed. Ultrasound is the recommended diagnostic tool, in addition to the clinical examination, for the differential diagnosis and during follow-up.

Diagnostic difficulties of plunging ranula: case series

OBJECTIVES

To evaluate common pitfalls in diagnosing complicated plunging ranula, either due to misidentification of plunging ranula or alternative pathology (i.e. false negatives or false positives, respectively).

METHODS

A review of cases of plunging ranula seen in Middlemore Hospital, New Zealand, was performed. Diagnostically uncertain cases were identified and reviewed, taking particular note of clinical, radiological and surgical findings.

RESULTS

From our database, 12 cases were found to have had a complicated diagnosis of plunging ranula. Ten cases were false negatives: four were treated as abscesses, four as simple cysts, one as a thyroglossal cyst and one as a cystic hygroma. Two cases were false positives: one was found to be a thyroglossal cyst and the other a lipoma.

CONCLUSION

The diagnosis of plunging ranula is usually straightforward, with simple surgical management. Misdiagnosis can lead to recurrence of symptoms and inappropriate management, with the associated risks, complications and frustrations of surgery.