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 Table of Contents  
CASE REPORT
Year : 2014  |  Volume : 3  |  Issue : 2  |  Page : 105-107

Ranula in an adolescent patient


1 Department of Pedodontics and Preventive Dentistry, Sinhgad Dental College and Hospital, Pune, India
2 Department of Periodontology, Hitkarni Dental College and Hospital, Jabalpur, Madhya Pradesh, India
3 M.A. Rangoonwala Dental college and Hospital, Pune, India
4 Sinhgad Dental College and Hospital, Pune, India

Date of Web Publication18-Jun-2015

Correspondence Address:
Dr. Rashmi Singh Chauhan
Department of Pedodontics and Preventive Dentistry, Sinhgad Dental College and Hospital, Pune, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2277-4696.159095

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  Abstract 

Ranula is a mucus extravasation cyst arising from the sublingual gland. The name "ranula" has been derived from the Latin word "rana" which means "frog." The swelling resembles a frog's translucent underbelly or air sacs. Ranula usually appears as a painless, fluctuant swelling. It usually occurs unilaterally and in young adults. This paper reviews and highlights a case report of ranula in the floor of the mouth that has been successfully treated by marsupialization. A 14-year-old female suffered from unilateral swelling in the floor of the mouth that had been enlarging slowly over the past 4 months. Conventional marsupialization was done. No complication was observed during the postoperative period, and there was no recurrence in the 24 months follow-up period.

Keywords: Marsupialization, ranula, sublingual salivary gland


How to cite this article:
Chauhan RS, Chauhan VS, Shirol D, Lele G. Ranula in an adolescent patient. J Dent Allied Sci 2014;3:105-7

How to cite this URL:
Chauhan RS, Chauhan VS, Shirol D, Lele G. Ranula in an adolescent patient. J Dent Allied Sci [serial online] 2014 [cited 2019 Jun 25];3:105-7. Available from: http://www.jdas.in/text.asp?2014/3/2/105/159095


  Introduction Top


A ranula (Latin word rana, meaning frog) describes a blue, translucent swelling in the floor of the mouth, reminiscent of the underbelly of a frog. [1] It is an uncommon type of mucus-filled cyst (mucocele) arising from the sublingual salivary glands in the floor of the mouth. Ranulas are characteristically large (>2 cm) and appear as a tense fluctuant dome-shaped vesicle, sometimes with a blue hue. The most common site is the lateral floor of the oral cavity. In very rare occasions, the mass may interfere with speech, mastication, respiration, and swallowing due to the upward and medial displacement of the tongue. [2]

A clinical variant with moderate incidence, plunging ranula, occurs when the fluid pressure of the mucin dissects through a perforation in the mylohyoid muscle in the submandibular space. [3],[4] The foremost etiology of ranulas is partial obstruction of a sublingual duct. This can lead to the formation of an epithelial-lined retention cyst, which occurs in <10% of all ranulas. The second most common factor is a trauma that causes direct damage to the duct or deeper areas of the body of the sublingual gland, leading to extravasation of mucus and formation of a pseudocyst. In most cases, it is iatrogenic.

Ranulas have a prevalence of about 0.2 cases per 1,000 persons and accounts for 6% of all oral sialocysts. The number of ranulas that represents a true retention cyst ranges from <1% to 10%. Ranulas usually occur in children and young adults, with the peak frequency in the second decade. These lesions have been classified into three clinical types according sites of the primary swelling: Oral ranula (intraoral swelling only), plunging ranula (submandibular and/or submental swelling without intraoral swelling), and mixed ranula (intraoral and extraoral swelling). [5] The cervical variant tends to occur a little later in the third decade.

The diagnosis of a ranula is usually determined by a combination of history, clinical presentation, histopathological presentation, and imaging studies. The therapeutic options for ranulas are aimed at either surgical excision of the lesion or attempts at inducing fibrosis and scarring that would eliminate the formation of the ranula. [6],[7],[8] These interventions can range from the simple incision, marsupialization with or without packing, excision of the ranula with or without the sublingual gland, laser vaporization, and the use of sclerosing agent OK-432. [6],[9]


  Case Report Top


A 14-year-old female patient reported to the Department of Pedodontics and Preventive Dentistry with the chief complaint of swelling in the floor of mouth [Figure 1] since past 4 months. Swelling ruptured on its own and reappeared every 3 rd to 4 th day and slowly increased in size. Every time it broke, thin watery fluid discharged from it. Patient also complained of intermittent pain associated with the swelling in the lower right posterior region. Patient gave the history of using a toothpick in the same region around 1-year back. The patient had no history of chronic illness or history of any operations in the oral cavity. Family history and personal history were not remarkable. On examination, the general condition was good and vital signs were stable. General physical examination was not significant.
Figure 1: Intraoral preoperative photograph of the patient

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Extraoral examination revealed a single, oval, enlarged right submandibular lymph node which was tender on palpation. There were no neck swellings. Intraoral examination described an uncommon blue, translucent, and soft fluctuant swelling in the anterior part of right side of floor of mouth which extended from lower right incisor till mesial surface of 1 st molar region measuring 3 cm × 4.5 cm × 5 cm in diameter. The tongue was raised. Results from hematological and biochemical investigations including complete blood count, erythrocyte sedimentation rate, liver function tests, kidney function tests, random blood sugar were all within normal limits. Chest X-ray was normal.

On the basis of history, clinical examination, and histologic examination the patient was diagnosed to have a large oral ranula, arising from the ruptured duct of the sublingual gland in the floor of the mouth. Marsupialization [Figure 2], [Figure 3], [Figure 4] of the lesion was done under local anesthesia, followed by suturing. Following surgery, the patient was placed on a normal diet, 5 days of therapy with antibiotic and analgesic orally. The sutures were removed 7 days after the surgery [Figure 5]. Postoperative follow-up of 24 months showed no recurrence.
Figure 2: Surgical marsupialization of the lesion

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Figure 3: Surgical marsupialization of the lesion-unroofing of the cyst

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Figure 4: Surgical marsupialization of the lesion-tacking the edges of the cyst to adjacent tissues

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Figure 5: Intraoral postoperative photograph of the patient

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  Discussion Top


Oral ranula is an infrequent pathology, usually occurring in children and adolescents. [10],[11] Obstruction of excretory ducts or extravasation and subsequent accumulation of saliva from the sublingual gland in the tissue are responsible for the formation of ranulas. [12],[13] Trauma to the floor of the mouth or neck region may rupture the sublingual gland acini or cause obstruction of the sublingual gland ducts, which results in mucus extravasation. In our study too, the patient gave the history of trauma. Clinically, the oral ranula, though they are generally small to medium in size, displaces the tongue, and interferes with oral function. Usually they are asymptomatic, although large ranula can cause esthetic and functional problems.

The diagnosis of ranula is based principally on the clinical examination and histopathological examination and sometimes on computerized tomographic or magnetic resonance imaging findings for the plunging lesion. Chemical analysis of aspiration fluid can reveal high amylase and protein contents consistent with secretions from the mucinous acini in the sublingual gland. Sialography provides minimal information in this lesion. [14] The differential diagnosis of ranula should include masses and swellings in the floor of the mouth and submandibular space region. These are dermoid and epidermoid cysts, branchial cleft cysts, thyroglossal duct cysts, cystic hygroma, lipomas, abscess, and malignant neoplasia. [3],[14],[15] Histologically, ranula consists of a central cystic space containing mucin and a pseudocyst wall composed of loose, vascularized connective tissues. An important feature in the histologic diagnosis is the absence of epithelial tissues in the pseudocyst wall. [16]

There are several different methods of treatment for ranulas. These include excision of the ranula via an intraoral or cervical approach, marsupialization, intraoral excision of the sublingual gland and drainage of the lesion, and excision of the lesion with the sublingual gland. Besides surgical management, CO 2 laser has been used to vaporize ranulas. [17] In rare cases, radiation therapy is an alternative. Low doses of 20-25 gray are effective. Intracystic injection of the streptococcal preparation, OK-432, has been used to treat this lesion in a few reported cases. The use of this sclerosing agent as a treatment approach for the cervical ranula is considered experimental. [18],[19] A recent study found orally administered Nickel Gluconate-Mercurius Heel-Potentised Swine Organ Preparations D10/D30/D200, a homotoxicological agent to be an effective treatment modality for ranulas. [11]

Crysdale et al. reported that the recurrence rate was 100% in cases with incision and drainage, 61% in cases of simple marsupialization, and 0% in case of excision of the ranula with or without sublingual gland excision. [20] As ranulas are usually extravasation pseudocysts developing after disruption of sublingual gland elements, many authors advocate that excision of the ipsilateral sublingual gland is the management approach of choice. [3],[20] However, the lingual nerve and submandibular duct, which are close to the sublingual gland, will be at risk for injury from this approach, especially in infant patients. Spontaneous resolution may be an option for the pediatric population. If the lesion does not resolve after 6 months observation for spontaneous resolution or recurs repeatedly, surgical treatment is recommended. [21]

In the present case of ranula, the patient gave a history of trauma, which subsequently went on to develop a massive oral ranula. Despite its extensive ramifications, the lesion was still successfully managed by simple marsupialization, along with suturing. Conventional marsupialization has a higher recurrence rate according to authors. [22],[23] In our opinion, complete removal of a ranula is technically very difficult to achieve as it involves an extremely fine mucosa that will usually rupture on excision. The most ideal treatment is therefore marsupialization if there is no neck swelling.

 
  References Top

1.
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. 1
    
2.
Regezi JA, Sciubba JJ, editors. Oral Pathology, Clinical Pathologic Correlations. 3 rd ed. Philadelphia: WB Saunders Company; 1999. p. 220-2.  Back to cited text no. 2
    
3.
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. 3
    
4.
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. 4
    
5.
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. 5
    
6.
Harrison JD. Modern management and pathophysiology of ranula: Literature review. Head Neck 2010;32:1310-20.  Back to cited text no. 6
    
7.
Huang SF, Liao CT, Chin SC, Chen IH. Transoral approach for plunging ranula-10-year experience. Laryngoscope 2010;120:53-7.  Back to cited text no. 7
    
8.
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. 8
    
9.
Lai JB, Poon CY. Treatment of ranula using carbon dioxide laser - Case series report. Int J Oral Maxillofac Surg 2009;38:1107-11.  Back to cited text no. 9
    
10.
Zhi K, Wen Y, Ren W, Zhang Y. Management of infant ranula. Int J Pediatr Otorhinolaryngol 2008;72:823-6.  Back to cited text no. 10
    
11.
Garofalo S, Briganti V, Cavallaro S, Pepe E, Prete M, Suteu L, et al. Nickel Gluconate-Mercurius Heel-Potentised Swine Organ Preparations: A new therapeutical approach for the primary treatment of pediatric ranula and intraoral mucocele. Int J Pediatr Otorhinolaryngol 2007;71:247-55.  Back to cited text no. 11
    
12.
Iida S, Kogo M, Tominaga G, Matsuya T. Plunging ranula as a complication of intraoral removal of a submandibular sialolith. Br J Oral Maxillofac Surg 2001;39:214-6.  Back to cited text no. 12
    
13.
Balakrishnan A, Ford GR, Bailey CM. Plunging ranula following bilateral submandibular duct transposition. J Laryngol Otol 1991;105:667-9.  Back to cited text no. 13
    
14.
Anastassov GE, Haiavy J, Solodnik P, Lee H, Lumerman H. Submandibular gland mucocele: Diagnosis and management. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000;89:159-63.  Back to cited text no. 14
    
15.
Yuca K, Bayram I, Cankaya H, Caksen H, Kiroglu AF, Kiris M. Pediatric intraoral ranulas: An analysis of nine cases. Tohoku J Exp Med 2005;205:151-5.  Back to cited text no. 15
    
16.
Batsakis JG, McClatchey KD. Cervical ranulas. Ann Otol Rhinol Laryngol 1988;97(5 Pt 1):561-2.  Back to cited text no. 16
    
17.
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. 17
    
18.
Woo JS, Hwang SJ, Lee HM. Recurrent plunging ranula treated with OK-432. Eur Arch Otorhinolaryngol 2003;260:226-8.  Back to cited text no. 18
    
19.
Rho MH, Kim DW, Kwon JS, Lee SW, Sung YS, Song YK, et al. OK-432 sclerotherapy of plunging ranula in 21 patients: It can be a substitute for surgery. AJNR Am J Neuroradiol 2006;27:1090-5.  Back to cited text no. 19
    
20.
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. 20
    
21.
Pandit RT, Park AH. Management of pediatric ranula. Otolaryngol Head Neck Surg 2002;127:115-8.  Back to cited text no. 21
    
22.
Haberal I, Göçmen H, Samim E. Surgical management of pediatric ranula. Int J Pediatr Otorhinolaryngol 2004;68:161-3.  Back to cited text no. 22
    
23.
McGurk M. Management of the ranula. J Oral Maxillofac Surg 2007;65:115-6.  Back to cited text no. 23
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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