The plunging ranula

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

Key Clinical Message

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

Abstract

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

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.

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.

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.

Sublingual-plunging ranula as a complication of supraomohyoid neck dissection

Ranulas are rare cystic lesions resulting from damage or rupture of one or more of the ducts of the sublingual gland, that lead to mucus extravasation or dilatation of the gland's duct. Extravasation cysts are more common than retention cysts. We present a case of a 45-year-old male with a squamous cell carcinoma of the ventral surface of the tongue that was treated with excision of the oral lesion and bilateral supraomohyoid neck dissection without supplementary radiotherapy. A left myocutaneous platysma flap was raised for defect closure. Ten months postoperatively he presented complaining of swelling of the right submandibular region. The diagnosis, based on his medical anamnesis and the CT imaging, was a sublingual-plunging ranula. It is postulated that the ranula resulted from damage to the ducts of the sublingual gland during selective neck dissection. One year postoperatively there are no signs of recurrence either of the ranula or of the cancer. We suggest that sublingual gland excision and intraoral cyst marsupialization is a logical treatment for sublingual-plunging ranulas.

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.

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.

Two cases of plunging ranula managed by the intraoral approach

Two cases of plunging ranula are reported. Treatment consisted of the total removal of the sublingual gland and evacuation of the cystic contents by the intraoral approach. The cyst remained just after the surgery in both cases, but then gradually regressed and disappeared within two months after the surgery. These findings support total removal of the sublingual gland as being the best method of treatment. We believe that complete dissection of the cyst with cervical incision as well as drainage of the cystic contents are unnecessary when the diagnosis of the plunging ranula is confirmed.

Plunging ranula: clinical observations

BACKGROUND

The plunging ranula is a relatively uncommon phenomenon which represents a mucus escape reaction occurring from disruption of the sublingual salivary gland. We present a series of 20 patients managed at Green Lane Hospital (Auckland, New Zealand) over a 9-year period.

METHODS

A retrospective review of 13 patients with this condition was undertaken, and a prospective study was conducted on 7 patients. Information was collected on age, sex, ethnic origin, history of onset, predisposing factors, treatment, and outcome of treatment.

RESULTS

The patients were all young adults with a median age of 31 years. The sex distribution was relatively equal, with 11 men and 9 women. All patients were Maori or Pacific Island Polynesians. Six patients gave a clear history of preceding trauma to the neck or oral cavity. Two recurrences were seen, both in patients who had had the sublingual gland excised via a cervical approach. Five patients sustained lingual nerve damage during surgery. Full function recovered in four patients, but the complication was still present in the fifth patient at 2 years, after which he was lost to follow-up.

CONCLUSIONS

Plunging ranulas appear to occur with greater incidence in the Maori and Pacific Island Polynesian populations. The precise etiology of their predisposition is unknown, although local trauma or inherent mylohyoid dehiscences may play important roles. Removal of the sublingual gland via either a cervical or intraoral approach is important in the management of this condition. Excision of the pseudocyst is probably unnecessary and places surrounding structures at risk of damage, but a biopsy of the pseudocyst wall is important to confirm the diagnosis.

Non-nodal neck masses

Planar imaging has made significant contributions to the evaluation of patients with non-nodal neck masses. The clinical history, physical examination, and imaging characteristics of these lesions are often complimentary. Yet, planar imaging much more accurately defines the size, location, and extent of these lesions than is revealed on physical examination. The CT and MR characteristics are often sufficiently specific to arrive at the correct preoperative diagnosis in these patients. We present the classical radiographic and clinical features of several non-nodal neck masses.