Plunging ranula as a complication of intraoral removal of a submandibular sialolith

Plunging Ranula: A Case Report of a Rare Late Complication After Tongue Cancer Surgery

A plunging ranula is a benign cystic lesion in the neck formed due to mucin extravasated from a salivary gland, most commonly the sublingual gland. Ranulas have been described in association with congenital anomalies, trauma, diseases of the sublingual gland, and HIV; however, rarely, they may result as a complication of various oral and neck surgeries. Here, we report a rare case of plunging ranula that developed in an elderly male as a sequalae to surgery for tongue cancer. The patient had undergone a partial glossectomy with supra-omohyoid neck dissection for tongue carcinoma and nine months later presented with cystic swelling on the floor of the mouth that was followed by neck swelling. It was treated successfully by excision, and the histopathology confirmed the diagnosis of ranula. We postulate that the tongue cancer surgery could have caused an inadvertent injury to the ducts of the sublingual salivary gland and mylohyoid muscle, leading to the development of a plunging ranula. Our case reiterates that surgeons need to be aware of the anatomy of the submandibular and submental region to avoid any surgical trauma to the sublingual and submandibular glands and their ducts along with the associated mylohyoid muscle.

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.

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.

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: a case report

Plunging ranulas, also known as deep, diving, cervical or deep plunging ranula, usually appear in conjunction with oral ranula. Rarely, these ranulas may arise independent of oral swelling. A rare case of plunging ranula without oral swelling is discussed along with review of literature.

Lingual crevicular approach for the intraoral submandibular gland excision

INTRODUCTION

We present an intraoral submandibular gland excision via a lingual gingival crevicular incision which may be used for a patient with molars.

MATERIALS AND METHODS

This is especially true for a patient with severe scarring on the floor of the mouth due to previous infections, such as chronic sialadenitis and its corresponding treatments.

DISCUSSION

However, despite its technical difficulty, the intraoral approach may be considered for patients who care about their aesthetic appearance or patients who do not wish to undergo the cervical approach for other reasons.

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.

Ranula successfully treated by botulinum toxin type A: report of 3 cases

The conventional treatment of ranula is surgical procedure. We report an innovative method for ranula by using botulinum toxin type A on 3 patients. All 3 cases of ranula resolved after this minimally invasive therapy. The treatment complication was minimal.

Ranula: experience with 83 cases in Zimbabwe

PURPOSE

To document the clinical features, management, and outcome of ranulas in Zimbabwe.

METHODS

A retrospective review of clinical and pathologic records of 83 patients with ranulas who presented during the period of January 1981 to September 2003 was undertaken.

RESULTS

Thirty-six (43.4%) of the ranulas were in males and 47 (56.6%) in females. Sixty-one (73.5%) were in the 0 to 10-year-old age group. Oral ranulas (92.8%) were equally distributed on the right and left sublingual region. Six (7.2%) were plunging ranulas. In a study group of 38 patients, 88.5% of ranula patients were HIV-positive with 95% of them in the 0 to 10-year-old age groups. Excision of ranula with sublingual gland removal was done in 80.7% of the cases with 0% recurrence; marsupialization (cavity left open and cavity packed) was done in 12% (n = 10) of the patients with 20% (n = 2) recurrence.

CONCLUSIONS

Female predominance with no right or left sublingual region predilection was noted. Ranula was most common in the 0 to 10-year-old age group; 95% of this group were HIV positive. HIV salivary gland disease could be an etiologic factor. No recurrence was observed when the ranula was excised along with removal of the sublingual gland. Plunging ranula is uncommon.

Submandibular gland endoscopic resection: a cadaveric study

Recent advancement of head and neck surgery has been marked by the development of endoscopic and video-assisted minimally invasive surgery. This study reports the feasibility of endoscopic submandibular gland resection in human cadavers. Twelve submandibular gland resections were performed in six human cadavers. A 30 degrees angle endoscope and conventional surgical instruments were inserted through two 15 mm submandibular incisions. Dissection was carried out bluntly with scissors in an avascular plane superficial to the gland. No insufflation was needed since transcutaneous sutures lead to effective retraction. Facial vessels, the lingual nerve and Wharton's duct were identified and protected. Vascular ligatures were performed using surgical miniclips. After the procedure, an open submandibular dissection was performed to control the integrity of the anatomical structures. In all cases, the resection of the submandibular gland was successful without the need for an additional incision. Injuries of the facial artery and lingual nerve occurred when the procedure was carried out initially. The operative time decreased with training, from 120 min for the first cases to 35 min for the later ones. In conclusion, endoscopic submandibular gland resection is possible without major difficulty. Training and experience reduce the operative time and the complication rate.