Plunging Ranula in Children: Case Report and Literature Review

Plunging or Cervical Ranula as a Rare Cause of Respiratory Distress

The Plunging or cervical ranula is a mucus pseudocyst extension of the sublingual gland that is located below the mylohyoid muscle. In infants, owing to small sublingual and cervical space, clinically large cervical ranulas can lead to a significant impact on swallowing, crying, and even breathing (Carlini et al. in Pediatr Rep 8(4):6576, 2016; Övet et al. in Turk Arch Otorhinolaryngol 53(3):133-135, 2015). In these clinical pictures, we present a case of cervical ranula that grew in a short period leading to respiratory distress. This ranula was aspirated in a PICU setting to relieve respiratory obstruction before definitive surgery in the operation theatre.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12070-023-04419-4.

Outlandish manifestation of swelling in early childhood seen in the patient's floor of the mouth

Ranula is a cyst-like growth that occurs in the oral cavity beneath the tongue. It consists of saliva from a ruptured salivary gland or duct. Rather than just flowing directly from the glands into the oral cavity, saliva permeates the nearby connective tissues and creates a bubble. A ranula could indeed appear at any time span in a person's life for inexplicable reasons. A trauma such as an oral operation, a facial blow or nibbling the lower lip may possibly start one. The following is a case study of an early childhood boy who reported with a swelling in the floor of the mouth with unknown aetiology from the last 6 months.

Recurrent Plunging Ranula Due to a Sublingual Ectopic Gland: A Rare Clinical Entity

Ranula is a benign cystic lesion caused by the escape and collection of salivary mucus. Classically, it is divided into simple ranulas, a cystic mass in the floor of the mouth, and diving/plunging/cervical ranulas, a submandibular mass without apparent intraoral involvement. Although plunging ranula is a well-documented cause of neck swelling, its association with the presence of ectopic sublingual glands is extremely rare, with less than five cases reported. Other cervical cystic lesions may have the same clinical aspect; therefore, advanced diagnostic techniques like a CT scan or MRI play a critical role in early diagnosis. Different approaches have been used to treat ranulas, including non-invasive, minimally invasive, and surgical techniques. The purpose of this paper is to highlight a case report of a giant plunging ranula due to an anatomical aberration of the right sublingual gland, along with a significant literature review.

Ultrasound in the diagnosis and differential diagnosis of enoral and plunging ranula: a detailed and comparative analysis

Purpose

To develop sonographic criteria for ranula that to allow rapid and precise diagnosis, differentiation between enoral (ER) and plunging ranula (PR), and differential diagnosis from other competing pathologies in this region.

Methods

Patients who presented with or were referred with ranula between 2002 and 2022 were assessed in a retrospective study. After clinical investigation, ultrasound examinations were performed in all cases. Several sonographic parameters describing the echotexture, shape and size of ranulas, their relationship to important surrounding anatomical landmarks and the characteristic spreading pattern of ERs and PRs were elaborated and evaluated.

Results

207 ranulas were included (82.12% ERs and 17.87% PRs). The ranulas were all in close anatomical relationship to the sublingual gland (SLG) and mylohyoid muscle (MM). The echo texture was hypoechoic to anechoic in 97.6% of the lesions. In comparison with ERs, PRs were larger and irregular in shape significantly more often (P = 0.0001). There were significant differences between ERs and PRs in their exact location relative to the SLG (superficial, deep, anterior, each P = 0.0001; posterior, P = 0.03) and level of the MM (above, below, above and below, P = 0.0001 each). The exact extent and plunging pattern were depicted in all PRs, but naturally in none of the ERs.

Conclusions

The ultrasound criteria developed in this study, confirming previously published results, indicate that ultrasound is an excellent diagnostic tool for diagnosing ranula and differentiating between ERs and PRs.

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.

Role of ranulas in early diagnosis of Sjögren’s syndrome: A case report

BACKGROUND

Although the presentations of Sjögren’s syndrome (SS) are variable, ranging from mild dryness to wider systemic involvement, ranulas as early clinical signs were scarcely reported. Here, we present an adult patient with SS, who developed a unilateral simple ranula and was diagnosed primary SS 3 years later. We also provide a review of cases of SS and ranulas from 1980 to 2020.

CASE SUMMARY

A 22-year-old girl was found to have a left painless floor-of-mouth lesion 3 years ago, without obvious trauma or inducement. The diagnosis of a unilateral (left) simple ranula was made, and the ranula was surgically treated. Within 3 years after the ranula surgery, she developed acute lymphadenectasis in unilateral parotid twice without inducement, and ultrasonic examination revealed diffuse lesions in bilateral parotids and submandibular glands, which strongly suggested SS. Serologic tests and the unstimulated whole saliva flow rate confirmed the SS diagnosis.

CONCLUSION

Our study underlines that ranulas are early clinical signs of SS. As early diagnosis and early intervention of SS are important to obtain better outcomes, our findings underline the need for histopathological test after sublingual adenectomy and imaging detection of exocrine glands for the patients with ranulas.

Plunging Ranula: A Case Report

A plunging or diving ranula is a rare mucous fluid collection in the submandibular or parapharyngeal space resulting from damage or rupture of one or more ducts of the sublingual gland. The most common clinical presentation is a painless, slow-growing, pliable mass in the floor of the mouth, sometimes extending below the mandible through a defect in the mylohyoid muscle. This case report presents a young female patient who was suspected of having a plunging ranula. This case also highlights the role that sonography and other diagnostic tools play in the evaluation of this phenomenon.

Recurrent extensive plunging ranula: A rare case

Plunging ranula (PR) is a cystic mass presenting on the lateral side of the neck with or without a history of the usual presentation of an intraoral lesion. "PR" is recognized as an uncommon lesion that has been found predominantly in the third decade of life mostly in males. However, the exact prevalence of "PR" is not yet known. We report a rare case of an extensive PR that reached the parapharyngeal space in a 17-year-old Saudi female. The diagnosis was made when she presented to the ENT clinic with swellings in the right submandibular and right floor of the mouth. The diagnosis of "PR" with the absence of an oral lesion is very challenging and requires a detailed history, clinical examination, and radiological imaging. Different modalities of treatment have been discussed. However, the excision of ranula and the sublingual gland is the most effective way of management.

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.

Midline cervical swellings: What a paediatrician needs to know

Midline cervical swellings are a heterogeneous group of conditions in children. Careful clinical examination will allow a diagnosis to be made in many instances and appropriate investigations to be performed before referral to surgical services. The approach to clinical examination, investigation and management of the most common conditions is described.

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.