Management of infant ranula

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.

[Little frog in the mouth: a visual diagnosis?]

Ranula, from the Latin "little frog", is a retention cyst filled with saliva in the oral cavity. Simple ranulas most commonly affect the sublingual gland and typically present as a hemispherical bluish cyst on the floor of the mouth, making it a visual diagnosis. A 7-year-old girl presented with a swelling on the underside of the tongue, an uncommon location for a ranula that made diagnostic assignment difficult. The optimal treatment of a ranula is still controversial in the literature. Many authors favor surgery as the treatment of choice. Our case shows that a watch and wait approach with simple mechanical pressure on the cyst can be sufficient.

Modified Micromarsupialization as Treatment of Ranula in a Pediatric Patient

Ranulas are mucoceles located on the floor of the mouth. The main form of treatment for these lesions is surgical excision, but this can lead to complications such as hemorrhage, recurrence of the lesion, and damage to the lingual nerve. Thus, other therapeutic modalities are indicated, such as modified micromarsupialization, which is a simple technique and not associated with recurrences, and without the need of a new intervention in the postoperative period. An 11-year-old female child, nonwhite, presented with bubble-shaped lesion located on floor of the mouth, on the left side, with exophytic growth, sessile base, bluish coloration, measuring about 4.0 cm in diameter, showing well-defined limits, well-delimited contours and borders, smooth surface, and softened consistency. Under the diagnostic hypothesis of the ranula, a modified micromarsupialization was performed. After 90 days of observation, complete regression and repair of the lesion were observed, without recurrence. Modified micromarsupialization is a simple therapeutic modality, low cost, and well-tolerated by the patient, mainly the pediatric one, being considered very effective in the treatment of lesions of difficult clinical management, as the ranula.

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.

Benign Pediatric Salivary Gland Lesions

Salivary gland lesions are rare in pediatric patients. In addition, the types of salivary gland tumors are different in their distribution in specific sites in the major and minor salivary glands in children compared with adults. This article reviews benign neoplastic and nonneoplastic salivary gland disorders in pediatric patients to help clinicians to develop an orderly differential diagnosis that will lead to expedient treatment of pediatric patients with salivary gland lesions.

A Rare Case of Congenital Ranula in an Infant

Ranula is a mucus extravasation cyst originating from the sublingual gland on the floor of the mouth. Congenital ranula is very rare. We report a case of a 4-month-old girl with a congenital ranula in the floor of mouth. The ranula was treated first by marsupialization, but the cyst recurred after 1 week. Excision of the ranula was done and was successful.

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.

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.

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.

Mucoceles of the oral cavity in neonates and infants--report of a case and literature review

Oral mucoceles are common lesions that normally appear in the second decade of life. They are uncommon in neonates and infants. We present a case of a mucocele in a 10-month-old infant and review the literature regarding the epidemiology and treatment in this age group.

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.

Cryosurgery as an Effective Alternative for Treatment of Oral Lesions in Children

Children can exhibit a wide variety of oral pathologies, such as oral lesions, bone lesions, tumors, cysts and cutaneous lesions. Different techniques have been described for the treatment of these lesions, but all of them are invasive. This paper presents a series of cases that demonstrate the clinical efficacy of cryosurgery as an alternative to invasive surgical treatments of the most common oral lesions in children. This technique has been well tolerated by patients due to the absence of anesthesia, rapid healing and minimal bleeding. Cryotherapy has many applications in oral medicine and is an extremely useful alternative in patients to whom surgery is contraindicated due to age or medical history. It is a simple procedure to perform, minimally invasive, low-cost and very effective in pediatric dentistry clinic.

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.

Recurrent right sublingual ranula, concomitant with ipsilateral submandibular salivary gland aplasia

INTRODUCTION

Oral ranula is a retention cyst that arises from the salivary gland with recurrence rate of up to 25% after complete excision of ranula and up to 2% in case of complete excision of ranula and sublingual gland. Major salivary gland aplasia is a rare finding that is usually associated with other developmental anomalies.

PRESENTATION OF CASE

We report a 15-year-old female patient presented with recurrent intraoral cystic swelling that was documented to be sublingual ranula. CT scan revealed also the absence of right submandibular salivary gland with persistence of its Whartons duct. This combination has never been reported previously.

DISCUSSION

The combination of recurrent sublingual ranula associated with aplasia of ipsilateral submandibular salivary gland and persistence of Whartons duct has never been reported before in the literature, a finding that may provide the base for future research.

CONCLUSION

Further research may prove similar associations between oral ranula and salivary gland aplasia, which may have clinical implications on diagnostic and management plan decisions.

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.

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.

Surgical management of intraoral ranulas in children: an analysis of 17 pediatric cases

OBJECTIVE

The preferred treatment of pediatric intraoral ranulas remains controversial. We present our experience with ranulas at the Gyeongsang National University Hospital and review the literature.

METHODS

The study involved 17 children under 15 years of age who visited our hospital from 2001 to 2008 and were diagnosed with a ranula exceeding 2 cm in diameter. The age and gender of the patients, the surgical procedures, presurgical observation period, postsurgical follow-up period, and complications of each case were determined. The unruptured specimens were all subjected to detailed pathological analysis.

RESULTS

The patients were on average 9.3 years and there were 10 girls and 7 boys. Spontaneous resolution was not detected in any of the cases during the presurgical observation period. Indeed, in two cases, the ranula had increased in size. The ranula and sublingual gland (SG) were resected in all cases. The average operation time was 1h. Recurrence and complications were not detected in any of the cases. Pathological analyses revealed that there was no communication of the ranula with the SG in any of the cases.

CONCLUSIONS

Our experiences suggest that the presurgical observation period need not be longer than 3 months and that the resection of ranulas along with the ipsilateral SG is a safe and effective primary treatment for symptomatic pediatric intraoral ranulas that exceed 2cm in diameter.

Regression of both oral mucocele and parotid swellings, following antiretroviral therapy

HIV-salivary gland associated disease is a well accepted concept in the HIV-related literature. Parotid swellings, especially in its cystic benign lymphoepithelial form, have been largely reported. Oral mucoceles (ranulas) were also associated with HIV in some publications. The exact nature of this link between mucoceles and HIV is still to be clarified. The mainstream treatment of most of parotid pathologies and oral mucoceles remains surgical approach. Strong evidences do, however, exist about lymphopithelial lesions of parotid glands that have been successfully treated with antiretroviral drugs. We present a case of intraoral mucocele, coexisting with bilateral parotid gland lymphoepithelial lesions, on a 2-year-old HIV-positive patient. Both parotid gland swellings and the sublingual mucocele have completely regressed following antiretroviral therapy. No surgical intervention was required. Conversely to benign lymphoepithelial lesions of parotid glands, the regression of oral mucocele on HIV-positive patient, following antiretroviral drugs therapy appears to be a rare phenomenon.

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.

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.