What is new in management of pediatric 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.

New Conservative Approach for the Management of Recurrent Sublingual Ranula-A Case Report

Ranula is a rare and benign extravasation mucocele that is clinically characterized by asymptomatic sublingual or submandibular masses. Surgical excision is considered the most effective treatment approach, but it has been associated with high invasiveness and several complications (hemorrhage, damage to Wharton's duct, and lingual nerve injury). Over the past decade, more conservative therapies have been rapidly disseminated into clinical practice to seek a more effective and less traumatic approach for young patients. In this report, an 8-year-old female with an asymptomatic, recurrent sublingual ranula was treated using a conservative approach with marsupialization and an intracystic injection of a plaque remover (Hybenx^® gel). After incision of the cystic dome, Hybenx^® gel was applied into the cystic lumen for 20 seconds and then aspirated; next, the area was rinsed thoroughly with sterile saline solution before suturing. Ultrasound re-evaluation at 10 months and intraoral clinical examination at 24 months confirmed the absence of relapse. Our results support the hypothesis that marsupialization combined with intracystic injection of Hybenx^® gel could be an encouraging conservative treatment alternative for recurrent sublingual ranula in children. Further randomized controlled trials are needed to test this hypothesis.

[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.

Salivary Gland Disorders in Pediatric Patients: A 20 Years’ Experience

Salivary gland disorders are uncommon in children; they show a lower prevalence when compared to adults. The literature has a relative lack of information about the management and the different treatment protocols regarding these diseases. The aim of this research is to investigate the prevalence of both benign and malignant salivary gland disorders, focusing on diagnostic and therapy. An audit of patients diagnosed with salivary gland disorders was conducted from 2000 to 2020. 99 patients’ records were selected and analyzed: 51 males’ and 48 females’, age 10 ± 4 SD. Obstructive pathologies were the most frequently diagnosed (49 patients) followed by oncologic (21 patients), inflammatory (20 patients), rheumatologic (4 patients), malformative (3 patients) and infective disorders (2 patients). The parotid was the most affected major gland in 47 cases with a prevalence of diagnosis of juvenile recurrent parotitis (JRP) (40.4%), followed by the sublingual gland in 14 cases of ranula (100%) and the submandibular gland in 11 patients suffering from sialolithiasis (84.6%). Swelling was the most common symptom (75.7% of patients). Seven different neoplasms were documented. A greater prevalence of low-grade mucoepidermoid carcinoma among the malignant group (38.1% of oncologic cases) was noted. In regards to benign tumors, pleomorphic adenoma was the most common diagnosis (47.6% of cases). The symptoms and outcomes showed statistical significance concerning gender. Although salivary gland diseases in children and adolescents are rare, it is essential to observe and monitor all of the symptoms to intervene if necessary, as painless swelling is a symptom common from both benign and malignant diseases.

Transoral Complete vs Partial Excision of the Sublingual Gland for Plunging Ranula

OBJECTIVES

Plunging ranula is a pseudocyst of saliva extravasated from the sublingual gland (SLG) to the submandibular space. This is treated by transoral excision of the SLG or transcervical cyst excision that might differently affect surgical morbidity and recurrence. This study compared the clinical outcomes of complete vs partial excision of the SLG for plunging ranula.

STUDY DESIGN

A nonrandomized comparative study.

SETTING

Academic medical center.

METHODS

This study included 42 patients with plunging ranula who underwent complete or partial excision of the SLG with the evacuation of cystic content. Two surgical methods of complete or partial SLG resection were alternatively allocated to consecutive patients without randomization. The primary outcome was a postoperative recurrence. Secondary outcomes were operation time and complications.

RESULTS

Complete and partial excision of the SLG was performed in 22 and 20 patients, respectively, without injury to the Wharton's duct or the lingual nerve. Postoperative complications in 42 patients were minor with temporary events: hematoma, 1 (5%); tongue numbness, 2 (5%); dysgeusia, 4 (9%); and dysphagia, 2 (5%), which did not differ between patients with complete and partial excision of the SLG (P > .1). However, recurrence occurred in only 5 of 20 patients with partial SLG excision but none of 22 patients with complete SLG excision for a median follow-up of 36 months.

CONCLUSIONS

Complete SLG excision is preferred over partial SLG excision to treat plunging ranula for reducing postsurgical risks of complications and recurrence.

The piercing-stretching suture technique for the treatment of simple oral floor ranula

BACKGROUND

Oral floor ranulas are pseudocysts located in the floor of the mouth that result from the extravasation of mucus from a sublingual gland. Historically, there has been little consensus on the ideal first-line treatment. Currently, definitive treatment involves sublingual gland excision, which can injure the lingual nerve and submandibular duct. Minimally invasive surgical techniques have been proposed, but so far have been associated with a high rate of recurrence.

METHODS

The so-called piercing-stretching suture technique was performed in 14 naïve adult and paediatric patients (6 females, with a mean age of 20.3 years (range, 7-55 years)). Clinical and ultrasonographic evaluations were performed in all patients; post-operative sialendoscopy was conducted in two paediatric patients.

RESULTS

The surgical procedure was successful in all patients, and complete recovery of the ranula was seen in all but one of the patients who underwent suture replacement. No major or minor complications were encountered.

CONCLUSION

This minimally invasive procedure may be considered a reliable and first-line treatment for management of simple oral floor ranulas.

Ranula in children: Retrospective study of 25 years and literature review of the plunging variable

OBJECTIVE

The aim of this article was to conduct a 25-year retrospective study within an oral surgery department, on the incidence of the ranula in children and its ideal treatment, associated with a literature review on the plunging ranula in pediatrics.

METHODS

A retrospective review of the medical records of pediatric patients (0-12 years) from 1995 to 2020 was performed in an oral surgery department in Maringá/Brazil. The examined data included age of the patients, sex, clinical signs, time of evolution and follow-up, complementary exams, type of ranula, diagnostic hypothesis, surgical procedures and accesses, complications and recurrence. In addition, a literature review was carried out on the plunging ranula in children, using the MEDLINE database, from 1995 to 2020, with the search terms: "PLUNGING RANULA" OR "CERVICAL RANULA. A PICOS was established and PRISMA standards were followed.

RESULTS

In the retrospective study, of the 11 patients found, 10 were with simple ranulas and only 1 with plunging ranula. All patients were approached by intraoral access, and conservative treatments had higher recurrence rates. The case of plunging ranula was treated by intraoral resection of the sublingual gland and saliva drainage, and obtained good results with 15 years of follow-up. In the literature review, 372 articles were found, which 10 were qualitatively selected after inclusion and exclusion criteria. Excision of the sublingual gland was the most prevalent procedure, and intraoral and extraoral accesses had the same incidence, despite the fact that the last one had higher percentages of complications.

CONCLUSION

The treatment of ranulas is variable; however, it is proven that conservative methods have higher rates of recurrence. As for the plunging ranula, resection of the sublingual gland through intraoral access, associated with mucus leakage, is considered a safe and effective treatment.

A rare case of congenital ranula

Simple ranula is a cystic swelling confined to the floor of mouth while plunging ranula presents with extension to the neck. Congenital ranula presenting with symptoms of feeding difficulties is a very rare occurrence. There is paucity of literature regarding the management of large congenital ranula. Varied treatment options are described for the management of ranula with variable recurrence rate. In paediatric and adult patients, ranula is considered as a type of extravasation cyst and removal of sublingual gland is advocated to remove the sources of extravasation. Congenital ranula is usually a variant of retention cyst and should be treated with marsupialisation or simple excision of cyst while cyst excision with sublingual sialadenectomy should be reserved for recurrent cases.

Anomalies of the oral cavity in newborns

Examination of the oral cavity should be an essential part of the newborn assessment. Early detection of congenital disorders is essential to begin appropriate medical or surgical therapy and to prevent complications that could profoundly affect a child's life. The present review aims to describe the main anomalies of the oral cavity in infants and provide images in order to help the physician in current clinical practice.

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.

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

BACKGROUND

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

OBJECTIVE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Modern management of paediatric obstructive salivary disorders: long-term clinical experience

Recent technological improvements in head and neck field have changed diagnostic and therapeutic strategies for salivary disorders. Diagnosis is now based on colour Doppler ultrasonography (US), magnetic resonance (MR) sialography and cone beam 3D computed tomography (CT), and extra- and intracorporeal lithotripsy, interventional sialendscopy and sialendoscopy-assisted surgery are used as minimally invasive, conservative procedures for functional preservation of the affected gland. We evaluated the results of our long-term experience in the management of paediatric obstructive salivary disorders. The study involved a consecutive series of 66 children (38 females) whose obstructive salivary symptoms caused by juvenile recurrent parotitis (JRP) (n = 32), stones (n = 20), ranula (n = 9) and ductal stenosis (n = 5). 45 patients underwent interventional sialendoscopy for JRP, stones and stenoses, 12 a cycle of extracorporeal shockwave lithotripsy (ESWL), three sialendoscopy-assisted transoral surgery, one drainage, six marsupialisation, and two suturing of a ranula. Three children underwent combined ESWL and interventional sialendoscopy, and seven a secondary procedure. An overall successful result was obtained in 90.9% of cases. None of the patients underwent traditional invasive sialadenectomy notwithstanding persistence of mild obstructive symptoms in six patients. No major complications were observed. Using a diagnostic work-up based on colour Doppler US, MR sialography and cone beam 3D TC, children with obstructive salivary disorders can be effectively treated in a modern minimally-invasive manner by extracorporeal and intracorporeal lithotripsy, interventional sialendoscopy and sialendoscopy-assisted transoral surgery; this approach guarantees a successful result in most patients, thus avoiding the need for invasive sialadenectomy while functionally preserving the gland.

A 17-year surgical experience of the intraoral approach for ranulas

INTRODUCTION

The aim of this study was to analyze the clinical features and treatment outcomes in order to determine the optimal management of ranulas in our Oral and Maxillofacial Surgery department with long-term results.

PATIENTS AND METHODS

A retrospective study was performed to evaluate patients with a final diagnosis of a simple or plunging ranula at Lille Teaching Hospital from May 2000 to January 2017. Clinical data on ranulas that were reviewed included gender, age, symptoms, location of the lesion, surgical procedures, complications, recurrence and follow-up.

RESULTS

The 26 patients included in the study comprised 18 males and 8 females, ranging from 3-months to 38 years of age. A total of 27 ranulas were managed: 25 oral ranula and 2 plunging ranulas. Twelve patients had undergone marsupialization (44.4%), 7 patients had complete excisions of the ranula (25.9%) or partial excisions combined with marsupialization (14.8%) and 4 patients (14.8%) had undergone excision of the sublingual gland (SLG). Seven ranulas recurred (25.9%). Not a single case recurred following the excision of the SLG. Treatments that included marsupialization were associated with the lowest recurrence rate (16.7%) after SLG excision, followed by combined marsupialization and ranula excision (25%) and by ranula excision alone (57%). There were no major complications.

DISCUSSION

Long-term outcomes confirm the different surgical procedures available in the outpatient clinic for the management of ranulas based on our surgical experience. Transoral resection of the SLG should be the optimal treatment, producing the lowest recurrence rate.

Ranula: Current Concept of Pathophysiologic Basis and Surgical Management Options

Background

There is no consensus opinion on a definitive surgical management option for ranulas to curtail recurrence, largely from the existing gap in knowledge on the pathophysiologic basis.

Aim

To highlight the current scientific basis of ranula development that informed the preferred surgical approach.

Design

Retrospective cohort study.

Setting

Public Tertiary Academic Health Institution.

Method

A 7-year 7-month study of ranulas surgically managed at our tertiary health institution was undertaken—June 1, 2008–December 31, 2015—from case files retrieved utilising the ICD-10 version 10 standard codes.

Results

Twelve cases, representing 0.4 and 1.2% of all institutional and ENT operations, respectively, were managed for ranulas with a M:F = 1:1. The ages ranged from 5/12 to 39 years, mean = 18.5 years, and the disease was prevalent in the third decade of life. Main presentation in the under-fives was related to airway and feeding compromise, while in adults, cosmetic facial appearance. Ranulas in adults were plunging (n = 8, 58.3%), left-sided save one with M:F = 2:1. All were unilateral with R:L = 1:2. Treatment included aspiration (n = 2, 16.7%) with 100% recurrence, intra-/extraoral excision of ranula only (n = 4, 33.3%) with recurrence rate of 50% (n = 2, 16.7%), while marsupialisation in children (n = 1, 8.3%) had no recurrence. Similarly, transcervical approach (n = 5, 41.7%) with excision of both the ranula/sublingual salivary gland recorded zero recurrence. Recurrence was the main complication (n = 4, 33.3%).

Conclusion

With the current knowledge on the pathophysiologic basis, extirpation of both the sublingual salivary gland and the ranula by a specialist surgeon is key for a successful outcome.

Excision of sublingual gland as treatment for ranulas in pediatric patients

OBJECTIVE

The aim of this case study is to demonstrate that post-operative complication rates of sublingual gland excision for treatment of ranulas are equal to or less than alternative methods with a lower recurrence rate than other surgical methods.

METHODS

This was a retrospective review of pediatric patients from 2004 to 2015 at Children's Hospitals and Clinics of Minnesota. Sixteen ranulas and 6 plunging ranulas were treated via sublingual gland excision during this time frame. Data examined included age, gender, scans of the lesion, location and size of lesion, surgical procedures, complications, and recurrence.

RESULTS

There were 22 patients who met criteria. Only one patient had recurrence of the lesion (4.5%). One patient reported lateral tongue numbness post-operatively, and one patient had a hypoglossal nerve injury, with tongue deviation upon exam. Both of these complications were temporary and resolved within months of the procedure.

CONCLUSION

Although sublingual gland excision is a definitive treatment for ranulas, many surgeons still utilize other methods such as marsupialization, drainage of the cyst, or excision of ranula alone as the primary method of treatment due to concerns about complications. This retrospective study demonstrates that excision of the sublingual gland is both a safe and effective method of treatment for ranulas.

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.

Point-of-Care Ultrasound to Diagnose a Simple Ranula

In the following vignette we demonstrate the use of point-of-care ultrasound to diagnose a simple ranula.

Serious neonatal airway obstruction with massive congenital sublingual ranula and contralateral occurrence

Background

Congenital ranulas seldom occur, with bilateral presentation and prenatal diagnosis reported very rarely. We believe this is the first reported case of a neonate with a antenally diagnosed massive congenital ranula, who went on to develop a non-contiguous contralateral ranula, both contributing to obstruction in a complex paediatric airway.

Case report

A female neonate was born to a non-primagravid mother via a planned elective caesarean section due to a lower facial defect and oral cyst. Antenatal aspiration of the pseudocyst was performed under ultrasound guidance with limited success. In the immediate post-natal period a poor airway was observed and the cyst was subsequently marsupialised. With the development of macroglossia secondary to oedema and tongue base collapse the airway was secured through surgical tracheostomy. A subsequent ultrasound scan revealed the presence of a second solitary cystic mass on the contralateral side. After careful excision of the contralateral pseudocyst, tongue function improved, with the resolution of a safe airway which permitted successful decannulation. A planned definitive procedure antenatally did not result in the anticipated improvement in function. However the subsequent development of a second non-contiguous pseudocyst and further surgical management resulted in a safe airway, improved masticator function and the ability to thrive.

Conclusions

The prenatal diagnosis of congenital ranulas have been seldom reported, with no reported cases of contralateral occurrence and airway obstruction from an intraoral ranula. This rare case highlights the need for a well considered contingency plan when surgery is required for a neonatal airway at risk.

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A well considered plan is required when a neonatal surgical airway is required.

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Intra-oral ranulas can be initially managed with marsupialisation or cyst excision.

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Sublingual gland excision is more reliable but associated with higher risk.

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Sublingual gland excision should be reserved for recalcitrant cysts.