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CASE REPORT
Year : 2020  |  Volume : 13  |  Issue : 2  |  Page : 179-181  

Sublingual ranula: A case study and management modalities


1 Department of Surgery, 178 Military Hospital, Gangtok, Sikkim, India
2 Department of Anaesthesiology, 178 Military Hospital, Gangtok, Sikkim, India
3 Community Health Centre, Vizhinjam, Kerala, India

Date of Submission11-Aug-2019
Date of Decision17-Oct-2019
Date of Acceptance06-Jan-2020
Date of Web Publication28-Feb-2020

Correspondence Address:
M Arun Kumar
Department of Surgery, 178 Military Hospital, C/O 99 APO, Gangtok, Sikkim
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mjdrdypu.mjdrdypu_230_19

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  Abstract 


Ranula is a mucus extravasation cyst of the oral cavity, the incidence of which peaks in the second decade of life. In this case report, a young male presented with a slowly progressive swelling at the floor of the mouth which was diagnosed clinically as ranula. He underwent excision of the ranula. Three-month follow-up revealed no recurrence.

Keywords: Mouth, ranula, sialocysts


How to cite this article:
Kumar M A, Gupta R, Anjana S. Sublingual ranula: A case study and management modalities. Med J DY Patil Vidyapeeth 2020;13:179-81

How to cite this URL:
Kumar M A, Gupta R, Anjana S. Sublingual ranula: A case study and management modalities. Med J DY Patil Vidyapeeth [serial online] 2020 [cited 2020 Apr 5];13:179-81. Available from: http://www.mjdrdypv.org/text.asp?2020/13/2/179/279628




  Introduction Top


The term “Ranula” originates from the Latin word Rana meaning the “underbelly of a frog.” They usually remain asymptomatic or present with a painless bluish fluctuant swelling at the floor of the mouth.[1] Based on the clinical presentation, they are categorized into three types – sublingual, plunging, and sublingual plunging ranulas. The most common variety “sublingual ranula” presents with an intraoral swelling. Plunging ranulas are those which are located cervically beyond the mylohyoid and present externally. Sublingual plunging ranulas have both the components.[2]


  Case Report Top


A 23-year-old male presented with a slowly progressive swelling on the right side of the floor of the mouth for 2 months. The swelling was painless and did not cause difficulty in movements of the tongue. Clinical examination revealed a 3 cm × 2 cm bluish swelling at the floor of the mouth toward the right side. It resembled the classical description of frog's belly. The swelling was mobile, nontender, and transilluminant. There were no signs of any cervical extension [Figure 1]a and [Figure 1]b.
Figure 1: (a and b) Preoperative

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The patient was counseled regarding the surgery and the likely chance of recurrence in future. With his consent, he was taken up for deroofing of the cyst under general anesthesia. Intraoperative findings included a jelly-like transparent material which was removed followed by the excision of ranula and suturing of the mucosal defect with running sutures. Postoperative period was uneventful, and the patient was discharged on day 5 [Figure 2]a and [Figure 2]b.
Figure 2: (a and b) Intraoperative

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Histopathological examination of the specimen revealed chronic inflammatory infiltrate surrounding mixed mucous and serous glands with mucin without any evidence of atypia, dysplasia, or malignancy.

On follow-up after 3 months from surgery, the patient was asymptomatic and intraoral examination revealed minimal induration at the site of surgery with no recurrence [Figure 3]a and [Figure 3]b.
Figure 3: (a and b) Follow-up after 3 months

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  Discussion Top


Ranula accounts for 6% of all oral sialocysts, and the incidence peaks in the second decade of life. Even though the prevalence is 0.2/1000 cases, less than 10% are true cysts.[3] Mucus extravasation has been accepted as the developmental cause for ranulas.[4] The diagnosis of ranula is mostly clinical. There are no specific diagnostic tests. Common presentation includes a cystic fluctuant lesion which increases gradually over a period of time.[5] The differential diagnosis includes various inflammatory and neoplastic lesions of the sublingual and submandibular glands/lymph nodes, granulomatous, adipose tissue diseases, cystic hygroma, branchial or thyroglossal duct cysts, laryngocele, dermoid cysts, and epidermoid cysts.[6]

Multiple treatment modalities have been tried from the past for ranulas, most of them with recurrence. Placement of silk suture at the dome of the lesion[7] and micromarsupialization[8] had been practiced in the past. Modified micromarsupialization with the use of multiple sutures has been successful in the pediatric population.[9] Marsupialization followed by positive pressure gauze packing has resulted in the reduction of the recurrence rate to less than 12%.[10] Multiple authors have advocated radical management of all ranulas with the excision of the sublingual gland along with the ranula.[11],[12],[13] Some of them had even recommended size criteria with respect to consideration of removal of the gland.[14],[15] Various surgical approaches have also been described in the form of transoral approach as well as through the lingual surface of the mandibular alveolar process.[16],[17],[18] The use of fibrin glue after dissection of ranula and hydrodissection technique using saline, lidocaine, and epinephrine are the other surgical techniques which have been employed.[19],[20] Vaporization of the ranula using lasers[21] and intracystic injection of sclerotherapy agents[22] have also been employed with minimal lateral damage. Botulinum toxin has also been injected into the cyst with some success.[23]

In spite of the various surgical and nonsurgical modalities described in literature, excision of ranula along with the involved sublingual gland has been the most accepted method with low recurrence rate.[24] The recurrence rate varies from 3.8% for excision of ranula along with sublingual salivary gland to as high as 100% for incision and drainage.[3],[14],[24],[25]


  Conclusion Top


Although ranula accounts for a small percentage of oral cavity lesions, its diagnosis gains importance due to the fact that it mimics a variety of inflammatory, benign, and neoplastic lesions. The diagnosis is purely clinical. Surgical modalities are still favored over newer modalities of treatment probably due to the lack of large-scale data in support of newer modalities in terms of recurrence.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Morita Y, Sato K, Kawana M, Takahasi S, Ikarashi F. Treatment of ranula – Excision of the sublingual gland versus marsupialization. Auris Nasus Larynx 2003;30:311-4.  Back to cited text no. 1
    
2.
Horiguchi H, Kakuta S, Nagumo M. Bilateral plunging ranula. A case report. Int J Oral Maxillofac Surg 1995;24:174-5.  Back to cited text no. 2
    
3.
Zhao YF, Jia Y, Chen XM, Zhang WF. Clinical review of 580 ranulas. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2004;98:281-7.  Back to cited text no. 3
    
4.
Mizuno A, Yamaguchi K. The plunging ranula. Int J Oral Maxillofac Surg 1993;22:1135.  Back to cited text no. 4
    
5.
Roediger WE, Kay S. Pathogenesis and treatment of plunging ranulas. Surg Gynecol Obstet 1977;144:862-4.  Back to cited text no. 5
    
6.
Engel JD, Harn SD, Cohen DM. Mylohyoid herniation: Gross and histologic evaluation with clinical correlation. Oral Surg Oral Med Oral Pathol 1987;63:55-9.  Back to cited text no. 6
    
7.
Morton RP, Bartley JR. Simple sublingual ranulas: Pathogenesis and management. J Otolaryngol 1995;24:253-4.  Back to cited text no. 7
    
8.
Delbem AC, Cunha RF, Vieira AE, Ribeiro LL. Treatment of mucus retention phenomena in children by the micro-marsupialization technique: Case reports. Pediatr Dent 2000;22:155-8.  Back to cited text no. 8
    
9.
Sandrini FA, Sant'ana-Filho M, Rados PV. Ranula management: Suggested modifications in the micro-marsupialization technique. J Oral Maxillofac Surg 2007;65:1436-8.  Back to cited text no. 9
    
10.
Baurmash HD. Marsupialization for treatment of oral ranula: A second look at the procedure. J Oral Maxillofac Surg 1992;50:1274-9.  Back to cited text no. 10
    
11.
Catone GA, Merrill RG, Henny FA. Sublingual gland mucus-escape phenomenon – Treatment by excision of sublingual gland. J Oral Surg 1969;27:774-86.  Back to cited text no. 11
    
12.
Pandit RT, Park AH. Management of pediatric ranula. Otolaryngol Head Neck Surg 2002;127:115-8.  Back to cited text no. 12
    
13.
Bridger AG, Carter P, Bridger GP. Plunging ranula: Literature review and report of three cases. Aust N Z J Surg 1989;59:945-8.  Back to cited text no. 13
    
14.
Crysdale WS, Mendelsohn JD, Conley S. Ranulas – Mucoceles of the oral cavity: Experience in 26 children. Laryngoscope 1988;98:296-8.  Back to cited text no. 14
    
15.
Baurmash HD. A case against sublingual gland removal as primary treatment of ranulas. J Oral Maxillofac Surg 2007;65:117-21.  Back to cited text no. 15
    
16.
Patel MR, Deal AM, Shockley WW. Oral and plunging ranulas: What is the most effective treatment? Laryngoscope 2009;119:1501-9.  Back to cited text no. 16
    
17.
Galloway RH, Gross PD, Thompson SH, Patterson AL. Pathogenesis and treatment of ranula: Report of three cases. J Oral Maxillofac Surg 1989;47:299-302.  Back to cited text no. 17
    
18.
Kaneko K. Kaneko K. Plunging ranula: Report of a case. Acta Med Nagasaki 2011;55:77-79.  Back to cited text no. 18
    
19.
Takimoto T, Ishikawa S, Nishimura T, Tanaka S, Yoshizaki T, Komori T, et al. Fibrin glue in the surgical treatment of ranulas. Clin Otolaryngol Allied Sci 1989;14:429-31.  Back to cited text no. 19
    
20.
Choi TW, Oh CK. Hydrodissection for complete removal of a ranula. Ear Nose Throat J 2003;82:946-7, 951.  Back to cited text no. 20
    
21.
Mintz S, Barak S, Horowitz I. Carbon dioxide laser excision and vaporization of nonplunging ranulas: A comparison of two treatment protocols. J Oral Maxillofac Surg 1994;52:370-2.  Back to cited text no. 21
    
22.
Fukase S, Ohta N, Inamura K, Aoyagi M. Treatment of ranula wth intracystic injection of the streptococcal preparation OK-432. Ann Otol Rhinol Laryngol 2003;112:214-20.  Back to cited text no. 22
    
23.
Chow TL, Chan SW, Lam SH. Ranula successfully treated by botulinum toxin type A: Report of 3 cases. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2008;105:41-2.  Back to cited text no. 23
    
24.
Yoshimura Y, Obara S, Kondoh T, Naitoh S. A comparison of three methods used for treatment of ranula. J Oral Maxillofac Surg 1995;53:280-2.  Back to cited text no. 24
    
25.
Parekh D, Stewart M, Joseph C, Lawson HH. Plunging ranula: A report of three cases and review of the literature. Br J Surg 1987;74:307-9.  Back to cited text no. 25
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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