Management of pediatric plunging ranula

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.

Diagnosis and management of congenital floor of mouth masses: A systematic review

OBJECTIVES

Determine the utility of preoperative imaging and the optimal course of management for congenital floor of mouth (FOM) cysts in infants.

METHODS

A systematic review of the literature was performed conforming to PRISMA guidelines. Pubmed, Embase and Cochrane Library databases were queried to identify cases of infants with congenital floor of mouth masses. Patient demographics, presenting findings, imaging, management, complications, and outcomes were determined.

RESULTS

85 patients were evaluated. 98% of patients presented at 16 months of age or younger. The most common presenting symptom was submental mass or swelling, 31.3%. Among the patients that underwent imaging, the suspected diagnosis obtained from imaging findings was consistent with the final pathologic diagnosis 59% of the time reported and inaccurate 34% of the time. There were multiple definitive treatment modalities described in the literature review including surgical excision, 82.3%, marsupialization, 12.9%, chemical injection 2.3%, sclerotherapy 1.2%,% and radiation, 1.2%. Recurrence rate after initial definitive treatment was as follows, surgical excision, 8.8%, marsupialization, 80%, sclerotherapy, 100%, chemical injection, 50%, and radiation, 100%.

CONCLUSION

Preoperative imaging studies should not be relied upon alone to determine suspected pathology and subsequent management in pediatric patients with FOM masses. It may be beneficial for these patients to undergo primary surgical excision regardless of imaging studies or suspected pathology. Needle aspiration offers limited addition to pathologic diagnosis and should only be performed in the setting of acute symptomatic management. Surgical excision should be considered as definitive treatment modality in all patients with FOM masses, regardless of the suspected diagnosis of ranula. Further multi-institutional cohort studies could be invaluable to elucidate definitive treatment guidelines in this patient population.

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 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.

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.

Management of Paediatric Oral Ranula: A Systematic Review

Introduction

Ranula is mucous extravasation cyst that occurs in the floor of the mouth. There are various methods of management of paediatric oral ranula each of which has their own advantage and disadvantage.

Aim

The aim of this paper was to systematically review the available literature on the management of paediatric oral ranula.

Materials and Methods

A total of 64 articles were retrieved by electronic search. Based on the preset inclusion and exclusion criteria, a total of 21 articles were retrieved for full text analysis. The following characteristics were assessed from the retrieved articles: author, year of publication, study design, sample size, intervention, adverse effects and follow up period.

Results

The included studies consisted of the following study design: Seven articles were prospective clinical study, four articles were retrospective review, five articles were case series and five articles were case report. The mode of care varied from surgical excision to drug administration and lasers.

Conclusion

The data obtained from the review, display a lack of high quality study, with proper sample size and adequate follow up period. Further, randomized clinical trials are required to help the clinicians devise a best treatment approach for the management of paediatric oral ranula.

Plunging Ranula in Children: Case Report and Literature Review

Few cases of plunging ranulas (PRs) occur during childhood and the lesions are frequently misdiagnosed. Here, a PR in a child is reported along with a literature review. A seven-year-old female complaining of swelling in the midline neck, left-submandibular region, was evaluated. No oral cavity or major salivary glands abnormalities were detected. On palpation, a soft, painless, and fluid-containing mass was observed. The suspicion PR was performed by ultrasound. The diagnosis was confirmed with a histopathological examination. The lesion was removed with a cervical approach, without recurrence. PR is an uncommon condition in children under 10 years of age. Differential diagnosis depends on clinical examination and ultrasonography. A computed tomography-scan and magnetic resonance imaging can be performed if the diagnosis remains uncertain. In pediatrics, the key to success of the treatment may rely on the radical excision of the cyst and sublingual gland, via an intraoral or submandibular approach.

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.

Are the patients with anatomic variation of the sublingual/Wharton's duct system predisposed to ranula formation?

OBJECTIVE

To evaluate ranula development according to anatomic variation of the ductal system of sublingual gland (SLG), especially the presence of Bartholin's duct.

METHODS

The anatomic variation of SLG duct was prospectively investigated and compared between 55 consecutive patients with ranulas treated by SLG excision (group 1) and another 15 consecutive patients undergoing similar surgeries for other conditions (group 2). The ductal structures of SLGs and submandibular glands (SMG) were also compared between the pediatric patients and adult patients with ranulas.

RESULTS

In 32 of 55 patients with ranulas (58.2%) and 1 of 15 patients without ranulas (6.7%), the SLG showed an anatomic variation of the main duct called Bartholin's duct structure (P<0.01). Seventeen of 22 (77.3%) pediatric patients with ranulas had Bartholin's ducts and 15 of 33 (45.5%) adult patients with ranulas had Bartholin's ducts (0.01<P<0.05), but Bartholin's duct which opens near to the orifice of Wharton's duct was not found in this study population. Plunging ranulas that extravasate deep to the mylohyoid were observed in the 6 patients (4 children and 2 adults). There was no recurrence in all cases with ranulas.

CONCLUSIONS

Congenital anatomic variation of the ductal system of the SLG might be a possible cause of ranulas in the patients with simple ranulas, especially in pediatric patients. Surgical resection of the SLG is a better treatment choice for ranulas than other conservative treatments.

A Rare Cause of Acute Respiratory Distress: Cervical Ranula

Plunging or cervical ranula is a mucus extravasation pseudocyst arising from the sublingual gland that is located below the mylohyoid muscle. Clinically, if large enough, cervical ranulas can affect swallowing, speech, chewing, and even breathing. The acute presentation of ranulas, which are clinically known as slow-growing, painless masses, is rare. In this study, we present a case of cervical ranula that grew in a short period of 3 days and resulted in respiratory distress and that was operated in our clinic.

What is new in management of pediatric ranula?

PURPOSE OF REVIEW

Ranula is extravasation mucocele arising from the sublingual gland, influencing the swallowing or eating; this review focuses on the most recent literature pertaining to pediatric ranulas and aims to comprehensively describe the methods of diagnosis and management approaches.

RECENT FINDINGS

Ranulas consist of intraoral ranula and plunging ranula, which are frequently misdiagnosed, so it is vital for the differential diagnosis of pediatric ranulas to depend on the clinical examination, imaging and fine-needle aspiration cytology. Pediatric patients should first be observed for 6 months before other treatments. OK-432 could activate inflammatory reaction to induce shrinkage of pediatric ranulas. Marsupialization, incision with drainage and ranula excision alone, are associated with a high rate of recurrence, even marsupialization with packing and modified micromarsupialization should be prudently applied for primary treatment of intraoral ranula. Laser excision is considered an alternative treatment for intraoral ranula of pediatric patients because of low recurrence rates and surgical complications. Recently, sublingual gland with or without ranula excision is a reasonable and suitable choice for radical treatment in pediatric patients.

SUMMARY

The principal goal of pediatric ranula management is radical sublingual gland excision, sealing the mucus extravasates and lowest complications.

Value of sialendoscopy-assisted transoral sublingual gland resection for a plunging ranula: case report and review

OBJECTIVE

To highlight the value of sialendoscopy during transoral resection of the sublingual gland for a plunging ranula to prevent iatrogenic injury to the submandibular duct.

METHOD AND RESULTS

The clinical course of a 20-year-old male with a plunging ranula was analysed. The patient underwent transoral resection of the affected sublingual gland and pseudocyst. Sialendoscopy was used to confirm patency of the submandibular duct with placement of a Marchal dilator to aid in preservation of the duct during sublingual gland dissection. The sublingual gland was successfully removed, with no injury to the submandibular duct or lingual nerve. During follow up, the patient had slight numbness to the tip of the tongue, which resolved after 2-3 days. Post-operative examination showed the submandibular duct to be intact and there was no swelling of the submandibular area.

CONCLUSION

Sialendoscopy-assisted transoral sublingual gland resection for a plunging ranula is a safe and effective technique. Sialendoscopy aids in skeletonisation and preservation of the submandibular duct.

Symptomatic Floor-of-Mouth Swelling with Neck Extension in a 14-Year-Old Girl

A plunging ranula is a soft-tissue mass stemming from a mucous extravasation cyst of the sublingual gland which can herniate through the mylohyoid muscle. We describe a case in which a 14-year-old girl presented with a rapidly expanding mass on the floor of her mouth affecting her ability to swallow and speak and causing tracheal compression. The patient was initially managed conservatively with antibiotics and steroids; however, the mass continued to expand necessitating emergent bedside incision and drainage and subsequent surgical intervention. The pathophysiology and management options for ranulas are also discussed herein.

Salivary gland diseases in children

Salivary gland diseases in children are rare, apart from viral-induced diseases. Nevertheless, it is essential for the otolaryngologist to recognize these uncommon findings in children and adolescents and to diagnose and initiate the proper treatment.

The present work provides an overview of the entire spectrum of congenital and acquired diseases of the salivary glands in childhood and adolescence. The current literature was reviewed and the results discussed and summarized.

Besides congenital diseases of the salivary glands in children, the main etiologies of viral and bacterial infections, autoimmune diseases and tumors of the salivary glands were considered. In addition to the known facts, new developments in diagnostics, imaging and therapy, including sialendoscopy in obstructive diseases and chronic recurrent juvenile sialadenitis were taken into account. In addition, systemic causes of salivary gland swelling and the treatment of sialorrhoea were discussed. Although salivary gland diseases in children are usually included in the pathology of the adult, they differ in their incidence and some­times in their symptoms. Clinical diagnostics and especially the surgical treatment are influenced by a stringent indications and a less invasive strategy. Due to the rarity of tumors of the salivary glands in children, it is recommended to treat them in a specialized center with greater surgical experience.

Altogether the knowledge of the differential diagnoses in salivary gland diseases in children is important for otolaryngologists, to indicate the proper therapeutic approach.

Surgical treatment of oral and facial soft tissue cystic lesions in children. A retrospective analysis of 60 consecutive cases with literature review

OBJECTIVES

To present the experience in the treatment of soft tissue cysts of the orofacial region in children treated at the Department of Oral and Maxillofacial Surgery at Children's Hospital "A. and P. Kyriakou", Dental School, University of Athens.

STUDY DESIGN

This is a retrospective study including 60 young individuals, 4 months to 14 years old. Surgical treatment was provided under general anaesthesia, during a 13-year period from 2000 to 2012.

RESULTS

The majority of cysts were mucoceles (n = 36, 60.0%), followed by ranulas (n = 15 or 25.0%), dermoid cysts (n = 4 or 6.6%), branchial cysts (n = 2 or 3.3%), thyroglossal duct cysts (n = 2, 3.3%) and one case of cystic hygroma (n = 1 or 1.6%). The primary method of treatment was enucleation and secondary marsupialization.

CONCLUSION

It is very important to appreciate that although soft tissue cysts are benign lesions, some of them may grow to a large size and become a major threat, especially in developing orofacial regions in children. In addition, as some types of soft tissue cysts such as cystic hygroma show a tendency to recur, early examination and follow-up is required for the young population.

Floor of mouth masses in children: proposal of a new algorithm

OBJECTIVE

Many surgical techniques have been described to manage floor of mouth masses, but few studies have described the approach to these masses in children. This case series summarizes a single institution's experience with pediatric floor of mouth masses.

METHODS

We performed a retrospective chart review of all children who presented at our tertiary care facility with FOM masses between 2007 and 2012. Charts were reviewed for clinical presentation, preoperative, intraoperative and postoperative management.

RESULTS

Thirteen cases were retrieved: 6 dermoid cysts, 4 ranulas, 1 lymphatic malformation, 1 imperforate submandibular duct, and 1 enlarged salivary gland. In 10 of 13 patients, clinical diagnosis was consistent with postoperative diagnosis. Imaging was consistent with postoperative diagnosis in 8 of 9 cases. Ten of 13 masses were managed transorally; 7 were excised, 2 were marsupialized and 1 was managed with submandibular duct dilation. Three masses with a larger submental component, 2 dermoids and 1 ranula, were removed transcervically. Most patients undergoing transoral excision underwent nasotracheal intubation; patients who underwent marsupialization underwent orotracheal intubation. There were no recurrences, complications or postoperative infections. An additional surgical procedure was necessary in one patient.

CONCLUSION

Our cohort displays a common distribution of lesion types when compared to the literature. Low recurrence and infection rates are observed when oral masses are removed transorally, and masses with a larger cervical component are removed transcervically. More complex masses may warrant additional surgical procedures.

The plunging ranula: diagnostic difficulties and a less invasive approach to treatment

Plunging ranulas arise when a simple ranula extends beyond the floor of the mouth into the neck. Diagnosis is difficult even with modern imaging techniques as they mimic other neck lesions, and traditional treatment involves enucleation of the cyst from the neck. Despite this invasive surgery they tend to recur. We describe a less invasive approach to treatment and review the diagnostic pitfalls. From 2002 to 2011, eight patients presented with a plunging ranula. They were split into two groups: those for whom an incorrect diagnosis was made and those where a less invasive treatment approach was employed. Three patients were misdiagnosed with cervical lymphangioma and had inappropriately invasive surgery. Five patients with established plunging ranulas were treated using an intraoral approach alone, eliminating the need for a cervical incision. Misdiagnosis of a plunging ranula leads to extensive and unnecessary surgery. We propose an algorithm to simplify investigation that employs a low threshold for fine-needle aspiration cytology. The cases presented indicate that these lesions can be managed by a less invasive procedure than currently practised.

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.

Acute presentation of a plunging ranula causing respiratory distress: case report

OBJECTIVE

A plunging ranula is an uncommon cause of neck swelling which typically presents in a gradually progressive fashion. This report describes a rare case of acute presentation of a plunging ranula. The condition progressed rapidly to respiratory distress, requiring urgent surgery.

CASE REPORT

A 14-year-old male student presented with a rapidly enlarging neck swelling associated with a sublingual swelling. Computed tomography suggested the diagnosis of plunging ranula. Several hours after admission, the neck swelling became very tense and the sublingual swelling enlarged dramatically. The tongue was pushed upwards and backwards by the sublingual swelling, causing respiratory embarrassment and requiring urgent surgery. Four months after surgery, there was no evidence of recurrence.

CONCLUSION

To the best of the author's knowledge, this is the first case report of a plunging ranula progressing acutely and rapidly to cause respiratory compromise. The literature is reviewed and pertinent features concerning the diagnosis and management of plunging ranula are presented.

Recurrent plunging ranula

We report two cases of plunging ranula, which had recurred after marsupialization. Both were successfully treated by removal of the ipsilateral sublingual gland. A brief review of the literature regarding the treatment options is presented.

Surgery for plunging ranula: the lesson not yet learned?

Our objective is to review our experience with treatment of plunging ranula and examine the efficacy of transoral excision of sublingual gland as the principal treatment. This study comprises a case series with chart review. A secondary otolaryngology service was used as the setting. Retrospective analysis of patient records was performed for a series of 95 consecutive cases of plunging ranula, which presented to our department between January 2001 and February 2010. Clinical presentation, investigations, diagnosis, treatment, complications and outcome were recorded. Literature search was performed using MEDLINE and OLD MEDLINE. 81 cases of plunging ranula were treated surgically by transoral excision of sublingual gland and evacuation of ranula contents. Mean operating time was 75.3 min. Twelve patients had undergone previous surgery elsewhere. One patient in our series had a recurrence, needing excision of sublingual gland remnant. Two patients had trauma to submandibular duct requiring excision of submandibular gland. Other complications were minor and transient. Review of literature revealed many diverse methods of treating ranula, with varying results. Our series makes a substantial contribution to the number of plunging ranulas reported in the world, and supports the use of transoral sublingual gland excision as first-line treatment of plunging ranula.

Modern management and pathophysiology of ranula: literature review

BACKGROUND

There is a lack of consensus about the appropriate treatment of ranula. The objective of the present investigation was to produce a scientific basis for treatment.

METHODS

A review of the relevant literature is interpreted in the light of improved knowledge about the local anatomy and the pathophysiology of the salivary glands.

RESULTS

The oral and plunging ranulas are cystic extravasation mucoceles that arise from the sublingual gland and usually from a torn duct of Rivinus. The sublingual gland is a spontaneous secretor and the salivary flow is resistant to obstruction, which is caused by fibrosis induced by the extravasation. The submandibular gland is not a spontaneous secretor, is less resistant, and does not give rise to ranulas.

CONCLUSIONS

Effective treatment is removal of the involved unit of the sublingual gland or inducing sufficient fibrosis to seal the leak through which the mucus extravasates.

A retrospective study of ranula in two centres in Malaysia

INTRODUCTION

Ranula is a mucous extravasation cyst which occurs as a result of trauma or obstruction of the sublingual or minor salivary gland or the duct itself.

PATIENTS AND RESULTS

14 patients were seen at Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur and Hospital Tunku Ampuan Afzan, Kuantan, Malaysia between 2000 to 2006. There were six cases of intra-oral ranula and eight plunging ranula. Twelve patients underwent surgical intervention while two refused surgery. Four patients (33.3%) from those who had surgical intervention returned with recurrence; two (16.7%) had marsupialization and the other two (16.7%) had excision of the pseudocyst intraorally.

CONCLUSION

Excision and marsupialization remain as the treatment of choice in our centres.

Transoral approach for plunging ranula--10-year experience

OBJECTIVE/HYPOTHESIS

Plunging ranulas (PRs) are infrequently encountered. The origin of PRs is mostly from the sublingual gland (SLG). Different routes to manage PRs include marsupialization, simple SLG excision, and combined SLG and submandibular gland (SMG) excision either transcervically or transorally. In this study, we demonstrated our experience managing PRs via transoral excision of the SLG with marsupialization.

STUDY DESIGN

Retrospective study.

METHODS

We retrospectively reviewed 20 patients at Chang Gung Memorial Hospital, Linkou, between January 1999 and April 2009. All patients received preoperative computed tomography or magnetic resonance imaging and were clinically diagnosed with PR. At surgery, the SLG was excised transorally with preservation of Wharton's duct and lingual nerve. The mucus contents of the PRs were drained through the posterior edge of the mylohyoid muscle.

RESULTS

Two patients were found to have final diagnosis of lymphangioma. Eighteen patients were eligible for analysis. The age distribution ranged from 6 to 48 years old. Sexual distribution was equally distributed. The successful rate was 17/18 (94.4%) with a lingual nerve paresthesia rate of 2/18 (11.1%). The paresthesia persisted for 3 and 6 months, respectively. One recurrent patient was salvaged by excision of the SMG and ranula. The other two recurrent patients received excision of the SMG and cyst and had a final diagnosis of lymphangioma.

CONCLUSIONS

Transoral approach with excision of the SLG alone provides a high success rate (94.4%) with minor complications and could be the first choice in managing PRs. The results of this study confirm PRs mostly originate from the SLG.

Plunging Ranula: Congenital or Acquired?

OBJECTIVE: To review our clinical experience with plunging ranula and examine the evidence in support of our impression that plunging ranula has a genetic basis.

STUDY DESIGN: Case series with chart review.

SETTING: Secondary otolaryngology service.

SUBJECTS AND METHODS: Review of the medical records of a clinical series of 80 consecutive plunging ranulas in 77 patients was conducted, with recording of clinical and radiological findings, surgical treatment, and outcome. A literature review using MEDLINE and OLD MEDLINE was performed.

RESULTS: The majority of plunging ranulas had no intraoral component on clinical examination, although evidence of mucus extravasation from the sublingual gland could be found both radiologically and histologically in all cases. There were four patients with bilateral plunging ranula and one instance of siblings with unilateral plunging ranula. Maoris and Polynesians comprised more than 82 percent of our cases; this was a significant overrepresentation of these ethnic groups ( P < 0.0001). A very strong predominance of cases of Chinese origin was also evident in the literature.

CONCLUSION: The clinical findings and the supporting data from the literature, when viewed in light of information relating to the known anatomical anomaly of a dehiscence in the mylohyoid muscle and ectopic sublingual gland lying below the plane of the mylohyoid, appear to support the case for a genetic basis for this unusual clinical entity.

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

OBJECTIVES/HYPOTHESIS

Preferred treatment of oral/plunging ranulas remains controversial. We present our experience with ranulas at the University of North Carolina (UNC) and review the literature.

METHODS

Retrospective review. From 1990 to 2007, 16 oral ranulas and 10 plunging ranulas were treated at UNC. Combining the UNC series with the literature identified 864 cases for review. An online survey was conducted to identify current treatment patterns.

RESULTS

In the UNC series, procedures for oral ranulas varied from ranula excision (50%), combined ranula and sublingual gland excision (44%), excision of the ranula along with the sublingual gland and submandibular gland (6%). A cervical approach was used in nine plunging ranula cases. One case was treated transorally with sublingual gland removal and evacuation of the ranula. Otherwise, the plunging ranula was removed along with the sublingual gland (20%), submandibular gland (50%), or both (20%). One hundred fifty-one complications were identified from the literature. Recurrence was considered a complication and was most prevalent (63%). Nonrecurrent complications included tongue hypesthesia (26%), bleeding/hematoma (7%), postoperative infection (3%), and Wharton's duct injury (1%). Sublingual gland excision yielded the fewest complications (3%). Procedures and associated complication rates were: transoral excision of sublingual gland (3%); transoral excision of sublingual gland and ranula (12%); marsupialization (24%); transcervical excision of sublingual gland, submandibular gland, and ranula (33%); OK-432 (49%); and aspiration (82%).

CONCLUSIONS

Based on our review, definitive treatment yielding lowest recurrence and complication rates for all ranulas is transoral excision of the ipsilateral sublingual gland with ranula evacuation.

Pediatric salivary gland imaging

A variety of lesions occur in the pediatric salivary glands. With modern imaging techniques such as Doppler sonography, helical CT, and MRI, identification of a specific etiology is often possible. Knowledge of clinical information, normal anatomy, and imaging characteristics of salivary gland pathology are essential for appropriate radiologic evaluation. This review illustrates the various congenital, neoplastic, and inflammatory entities that can occur within the parotid, submandibular, and sublingual spaces.

Management of the pediatric plunging ranula: results of 15 years' clinical experience

OBJECTIVE

This study was designed to evaluate the diagnosis and surgical treatment of the plunging ranula in children.

STUDY DESIGN

A retrospective study of 129 pediatric patients with a clinical diagnosis of plunging ranula was conducted. All children underwent clinical assessment and fine needle aspiration cytology. Cytologic diagnosis was considered to be definitive, and radiologic investigations were not conducted. Intraoral excision of the ipsilateral sublingual gland and partial pseudocyst was performed for all patients.

RESULTS

The preoperative diagnosis was consistent with postoperative and histopathologic analyses in all cases. There were no recurrences at 36 months' follow-up. There were no long-term complications as of writing this report.

CONCLUSIONS

Fine needle aspiration cytology can be used as the routine method to reach a diagnosis for plunging ranula, especially in the absence of floor of mouth involvement. Intraoral excision of the ipsilateral sublingual gland and partial pseudocyst is an effective and safe method for the treatment of the plunging ranula in the pediatric population, with absence of recurrence and low morbidity.

Congenital neck masses

Congenital neck lesions reflect abnormal embryogenesis in head and neck development. A thorough knowledge of embryology and anatomy is critical in the diagnosis and treatment of these lesions. The appropriate diagnosis of these lesions is necessary to provide appropriate treatment and long-term follow up, because some of these lesions may undergo malignant transformation or be harbingers of malignant disease.

Primary treatment of pediatric plunging ranula with nonsurgical sclerotherapy using OK-432 (Picibanil)

OBJECTIVE

Although surgery is the first choice of therapy for plunging ranula, it is associated with technical difficulties, morbidity and recurrence. Plunging ranula may be also primarily treated with nonsurgical sclerotherapy, but there is little experience in pediatric patients. We, therefore, assessed the efficacy of OK-432 sclerotherapy for pediatric plunging ranula.

METHODS

Nine children with plunging ranula were prospectively treated with intracystic injections of OK-432. At the outpatient clinic, the ranula was punctured in the neck and aspirated mucus was replaced with 0.1-0.2mg OK-432 solution. The size of the ranula was compared before and after sclerotherapy.

RESULTS

Total or nearly total shrinkage was observed in 6 of 9 patients; marked reduction (>50% of original size) in 2; and partial reduction (<50% of original size) in 1. At a mean follow-up of 26 months after last sclerotherapy, recurrence was observed in only 1 patient; this patient showed complete response after reinjection of OK-432 solution. No significant complications were observed, with only fever and mild local pain observed in 4 patients for 2-4 days after treatment.

CONCLUSIONS

OK-432 sclerotherapy is safe and effective in the treatment of pediatric plunging ranula. Sclerotherapy may become a primary treatment modality prior to surgery.

Management of infant ranula

OBJECTIVE

Many surgical techniques to manage ranulas have been described in the literature. Ranula of infant patients was rare. Few studies have described the approach toward management in infant patients.

METHODS

Eleven infant patients were treated for intraoral ranulas. The methods of treatment included aspiration of mucus, marsupialization and excision of the ranula and the ipsilateral sublingual gland. All cases were performed aspiration of mucus and observed for 6 months; and the marsupialization were recommended if the ranula recurred; the surgical resection of ipsilateral sublingual gland were performed if the ranula recurred when infant patients was about 1-year-old. These patients were followed up at least 24 months.

RESULTS

Age of presentation ranged from 2 days to 3 months. There were six females (54.55%) and five males (45.45%). All cases presented simple (introral) ranula. Excision ranula with sublingual gland was performed on seven patients (63.64%) while marsupialization was performed on two patients (18.18%) and two patients (18.18%) were aspiration of the mucus of ranula and no recurrence. There were no recurrent lesions in all cases.

CONCLUSION

Conservative treatment of infant ranula maybe includes observation for 6 months for spontaneous resolution. The methods for observation is performed the aspiration of mucus and marsupialization. The resection of ipsilateral sublingual gland is recommended if ranula recurred for infant patients about 1-year-old. We believe that it is safe that the submandibular duct and complete sublingual nerve are dissected before the sublingual gland is removed.