Plunging Ranulas Revisited: A CT Study with Emphasis on a Defect of the Mylohyoid Muscle as the Primary Route of Lesion Propagation

Imaging of salivary gland cancers derived from a sublingual gland herniated into the submandibular space: a report of three cases

Sublingual gland herniation into the submandibular space through a mylohyoid muscle defect is a common anatomical variation; however, salivary gland cancers that arise from a herniated sublingual gland have not been described yet. Here, we report three patients with salivary gland cancers originating from a herniated sublingual gland. All tumors were detected as palpable submandibular masses, located anterior to the submandibular gland, medial to the mandible, and lateral to the mylohyoid muscle, with contact with the sublingual gland through a mylohyoid muscle defect. Intraoperative findings confirmed that the masses were derived from herniated sublingual glands. Pathological examination showed one case of mucoepidermoid carcinoma and two cases of adenoid cystic carcinoma. Imaging findings of the tumor location, in addition to the continuity with the sublingual gland through the mylohyoid muscle defect, are crucial for accurately diagnosing the tumor origin, which is essential for determining the appropriate clinical management.

Imaging evaluation of the benign and malignant lesions of the floor of the mouth: Pictorial review

The floor of the mouth is an important anatomical region of the oral cavity where primary benign and malignant disease processes can originate or secondary pathologies can extend into adjacent spaces. Knowledge of the anatomy is crucial for accurate localisation of pathology and understanding the spread of disease. The sublingual space is the dominant component of the floor of the mouth, bounded inferiorly by the mylohyoid muscle that separates it from the submandibular space. Imaging is immensely important to characterise and map the extent of disease, considering the fact that the bulk of the disease may be submucosal and not visible on clinical inspection.

Contribution

The floor of the mouth is a complex anatomical region for radiological evaluation. The purpose of this pictorial review is to present an understanding of the relevant anatomy and to demonstrate the role and appropriate application of different imaging modalities. This article highlights the imaging spectrum of a wide range of various benign conditions including normal variants and a variety of malignant lesions at different tumour stages, with an aim to establish the correct diagnosis, avoid misinterpretation and help in treatment planning.

Plunging Ranula Presenting as a Giant Anterior Cervical Cystic Mass: A Case Report and Literature Review

Plunging ranula, a subtype of ranula, commonly presents as a submandibular or submental cystic mass without oral counterpart, and its clinical management remains challenging. Herein, the authors report an extremely rare case of 30-year-old female patient with plunging ranula involving the root of the left anterior neck.

A Concise Review on the Utilization of Abbreviated Protocol Breast MRI over Full Diagnostic Protocol in Breast Cancer Detection

Breast MRI possesses high sensitivity for detecting breast cancer among the current clinical modalities and is an indispensable imaging practice. Breast MRI comprises diffusion-weighted imaging, ultrafast, and T2 weighted and T1 weighted CE (contrast-enhanced) imaging that may be utilized for improving the characterization of the lesions. This multimodal evaluation of breast lesions enables outstanding discrimination between the malignant and benign and malignant lesions. The expanding indications of breast MRI confirm the far superiority of MRI in preoperative staging, especially in the estimation of tumour size and identifying tumour foci in the contralateral and ipsilateral breast. Recent studies depicted that experts can meritoriously utilize this tool for improving breast cancer surgery despite their existence of no significant long term outcomes. For managing the, directly and indirectly, associated screening cost, abbreviated protocols are found to be more beneficial. Further, in some of the patients who were treated with neoadjuvant chemotherapy, breast MRI is utilized for documenting response. It is therefore essential to realise that oncological screening must be easily available, cost-effective, and time-consuming. Earlier detection of this short sequence protocol leads to prior and early breast cancer disease in high risky female populations like women with dense breasts, prehistoric evidence, etc. This proper utilization of AP reduces unnecessary mastectomies. Hence, this review focused on the explorative information for strongly suggesting the benefits of AP breast MRI compared to full diagnostic protocol MRI.

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.

Value of 18F-PSMA-PET/MRI for Assessment of Recurring Ranula

We report the case of a 6-year-old patient with suspected recurrence of a plunging ranula in clinical and ultrasonographic examination. Surgical resection of the left submandibular and sublingual glands had already been performed. Since persistent glandular tissue could not be excluded with certainty via MRI, we expanded diagnostics by performing a PET/MRI using a head and neck imaging protocol and the radiotracer ¹⁸F-PSMA-1007, which is physiologically expressed by salivary gland tissue. The ¹⁸F-PSMA-PET/MRI provided evidence of a cystically transformed, diminishing seroma in the left retro-/submandibular region. No ¹⁸F-PSMA expressing glandular tissue could be detected in the area of resection, excluding a relapse of a plunging ranula. As a consequence, we opted for a conservative treatment without further surgical intervention. We conclude that a simultaneous ¹⁸F-PSMA-PET/MRI is a comprehensive imaging modality, which can help to rule out persistent salivary tissue and recurring plunging ranula. It is a useful tool to facilitate the decision making of surgical interventions.

Excision of Sublingual Gland

There are 2 types of ranulas: oral ranulas and plunging (cervical) ranulas. The management of the cervical ranula involves surgical excision of the oral portion of the ranula along with the associated sublingual salivary gland. The sublingual gland is easily removed from an intraoral approach. Significant anatomic structures associated with the removal of the sublingual gland are the submandibular duct, lingual nerve, and sublingual artery. Knowledge of the anatomy makes the surgery easier and without complications.

[Plunging ranula presenting as a giant retroauricular mass: A case report]

Plunging ranula is rare and manifests as the submandibular or submental cystic mass, without intra-oral abnormality. It usually causes misdiagnosis and malpractice. This article reported a case of plunging ranula that appeared as a massive mass located behind the left ear. A 6-year-old child presented with recurrent left retroauricular swelling over six months without obvious inducement. The mass showed repeatedly swelling and persistent skin ulcers. Physical examinations described a fluctuant, nontender mass behind the left ear whose size was about 5 cm×5 cm×3 cm. The skin upon the surface of the mass was thin and red, and overflowed yellow slimelike contents. Computed tomography (CT) showed an extensive cystic lesion in the left neck. After local incision and drainage the mass was shrink. With the primary clinical diagnosis of branchial cyst, the patient underwent mass resection through postauricular incision. During the operation, the fistula was traced to the area around the sublingual gland, and the postoperative pathology report demonstrated cystic spaces occurring in soft tissue without lymphoid tissue. One month postoperatively, the patient presented the "egg-white", wire-drawing transparent viscous fluid outflowing from the left external auditory canal, indicating that the fluid in the external auditory canal originated from the sublingual gland and the disease was the plunging ranula presenting as a giant left retroauricular mass. We readmitted the patient to the hospital and the ipsilateral sublingual gland was completely removed in the mouth under general anesthesia. No clinical evidence of recurrence was found at the end of 9 months follow-up. So far, there is no literature reporting plunging ranula behind ear. This case report describes the clinical manifestation, diagnosis, and differential diagnosis and treatment of a case of plunging ranula, and reveals that, other than the submandibular or submental, plunging ranula also could be found in retroauricular region. The plunging ranula is difficult to fully confirm through a clinical character, and usually easy to be misdiagnosed as other tumors, like lymphatic malformation, venous malformations, etc. Radiographic examination and/or puncture fluid observation are required for identification. "Egg-white", wire-drawing mucous secretion is the most important characteristic in clinical diagnosis of sublingual gland cyst. However, if sublingual gland resection, i.e. removal of the source of cyst fluid is performed, a good prognosis can be achieved.

Plunging Ranulas and Prevalence of the "Tail Sign" in 126 Consecutive Cases

OBJECTIVES

Plunging (or diving) ranulas are extravasation pseudocysts arising from the sublingual gland that present as soft submandibular swelling. The "tail sign" has been widely reported as pathognomonic for their diagnosis. It is described as a smooth tapering comet-shaped unilocular fluid mass with its "tail" in the collapsed sublingual space (SLS) and its "head" in the posterior submandibular space. This sign is based on the premise that extravasated saliva from the sublingual gland in the SLS escapes and plunges, over the posterior edge of the mylohyoid muscle into the submandibular space. Therefore, some fluid must be present in the posterior SLS in almost all patients with plunging ranulas. This study aimed to determine the frequency of fluid seen with ultrasound (US) in the posterior SLS to corroborate the tail sign.

METHODS

A total of 126 consecutive cases of surgically proven plunging ranulas were investigated with US over 13 years. The findings were reviewed retrospectively for the prevalence of fluid in the posterior SLS.

RESULTS

Thirteen patients (10.3%) showed SLS fluid on US images. Most showed fluid extension through a mylohyoid dehiscence. Only 2 patients (1.6%) showed fluid within the posterior SLS, and 1 patient alone in this entire study showed all of the components of the classically described tail sign.

CONCLUSIONS

This largest ever radiologic study showed low prevalence of the tail sign in 2 of 126 patients. A mylohyoid dehiscence was the more common route for extravasation. Absence of the tail sign does not exclude the diagnosis of a plunging ranula.

Histologic features of sublingual gland herniation through the mylohyoid muscle

OBJECTIVES/HYPOTHESIS

The purpose of this study was to document histologic features of the herniated sublingual gland (SLG) and investigate the histologic correlation between herniated SLG and plunging ranula.

METHODS

One hundred half-heads from 50 adult cadavers (21 females and 29 males) were included in this study. The presence of SLG herniation and the histologic features SLG were analyzed. The histologic features were analyzed according to the part: intraoral, junctional, and herniated parts. Hematoxylin and eosin (H&E), periodic acid Schiff reaction (PAS), and Alcian Blue (pH 2.5) staining were performed.

RESULTS

SLG herniation was found in 42 of 100 half-heads. Non-herniated SLG and the intraoral part of the herniated SLG were mainly composed of mucous acini and a few mixed acini. Junctional and herniated parts were mainly composed of serous acini and showed fatty change. PAS and Alcian blue staining showed that both acidic and neutral mucinous acini of junctional and herniated parts were decreased. However, there was no pseudo-epithelium at any site of herniation.

CONCLUSIONS

The histologic features of herniated SLG are different according the portions. The herniated part showed fatty degeneration and the remaining acini were mainly serous. We cannot confer any correlation between plunging ranula and the herniated part of SLGs.

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.

Surgical management of plunging ranulas: a 10-year case series in South East Queensland

BACKGROUND

Plunging ranulas are rare mucous extravasation pseudocysts that arise in the floor of the mouth and pass into the submandibular space of the neck. The aim of this study was to investigate the diagnosis, surgical management and outcomes of patients with a plunging ranula at our institution in South East Queensland over a 10-year period.

METHODS

A retrospective analysis of adult patients diagnosed with and treated for plunging ranula between 2006 and 2016 at Logan Hospital was conducted. Patient demographics, preoperative investigations, surgical management and post-operative outcomes were collected from medical records.

RESULTS

A total of 18 adult patients were treated for plunging ranula. Of the 18 cases, 17 were treated via transoral excision of the sublingual gland. The mean age at presentation was 28.8 years with a 3:1 female to male predominance. Fifty-six percent of patients were of Polynesian descent. The success rate was 94% with only one patient experiencing recurrence and requiring re-excision of remnant sublingual gland tissue. Three patients (17%) developed complications related to post-operative bleeding. There was a slight predominance for right-sided disease (56%) compared with left and one case of bilateral plunging ranulas in this series.

CONCLUSION

This study demonstrates that excision of the sublingual gland is an effective and safe treatment for plunging ranula. The majority of plunging ranulas occur in patients aged <30 years with a higher incidence in patients of Polynesian heritage, which is consistent with previous studies suggesting a possible underlying genetic predisposition for this condition.

Ectopic Salivary Gland Cyst in the Neck: Association with Congenital Plunging Ranula

Congenital ranula is rare. We report a large, symptomatic, congenital plunging ranula associated with a salivary gland cyst in the neck. To the best of our knowledge, this is the first such reported case. Even though both the cysts had their origin from the sublingual gland, only the cervical cyst had a capsular covering. Herniation of a part of the immature sublingual gland anlage through a congenital mylohyoid defect, its separation, and subsequent maturation could explain this occurrence.

A cadaveric study on mylohyoid herniation of the sublingual gland

The purpose of this study was to document the presence of a sublingual gland (SLG) herniating inferiorly through the mylohyoid muscle into the submandibular area. A total of 100 half-heads of 50 adult Korean cadavers were enrolled in this study. The floor of the mouth was dissected from the neck, and mylohyoid muscle patency and position of the sublingual gland were evaluated. Demographic factors of the donor and characteristics of the herniation were evaluated. Herniation was found in 29 (58.0 %) of the 50 cadavers or 42 of the 100 half-heads. Herniation was more frequently observed in females than in males (p = 0.009). However, no laterality was observed. Classifying the location of SLG herniation from the midpoint of the mandible to the hyoid bone into 3 regions, 32 (63 %) of herniations were found in the anterior one-third. No ranula formation was observed. The size and weight of normal glands tended to be larger than those of herniated glands, but no statistical significance was observed. An SLG hernia is a very common condition and is more frequently observed in females. As such, SLG herniation should be considered when a submental neck mass is evaluated.