Surgical Management of an Oral Ranula in a Pre-schooler

Keywords

Ranula; Pediatric; Excision; Sublingual Gland.

Background

The term ranula is derived from the Latin word ‘‘rana’’ and is descriptive of the blue, translucent swelling in the floor of mouth, which is said to resemble the underbelly of a frog. Ranulas may be simple or plunging. [1, 2] A simple ranula can be either a mucus retention cyst or more commonly a mucus extravasation pseudocyst, which is confined to the floor of the mouth. A plunging or cervical ranula is a mucus extravasation pseudocyst arising from the sublingual gland and presents as a swelling in the neck. [3]

A ranula is relatively painless or asymptomatic with little or no associated morbidity or mortality but if the size is large, it may interfere with deglutition, speech, mastication or breathing. [4] Literature on managing pediatric oral ranulas state that incision followed by drainage frequently causes recurrence because of the early closure of the incised portion [5], persistent extravasation of sublingual gland and without the development of granulation and fibrous tissue that obstructs the extravasation. [6, 7] This report summarises the management of a pediatric oral ranulaby a transoral excision of the ranula along with the sublingual gland.

Case Report

A 4 year old female child reported with a complaint of a swellingon the right side below the tongue for the past 5 months. The parent gives a history of a swellingwhich would tend to enlarge and then spontaneously drain into the mouth having a salty taste with recurrence every 2 weeks. She also described difficulty in swallowing & moving her tonguewhen the swelling would enlarge. There was no history of trauma, infection, or known precipitating factors. On examination there wasa 2 cm ovoid swelling in the right floor of mouth which was bluish grey in colour (Fig 1). On palpation the swelling was soft and non-tender. A presumptive diagnosis of a ranula was made. Considering the age of the child and the invasive procedure planned, the treatment was planned under general anaesthesia. A transoral excision of the mass and sublingual gland was performed. The lingual nerve was identified to permit complete removal of the right sublingual gland and its excision was done (Fig 2). The mucosal incisions were reapproximated and sutured with absorbable sutures. The excised tissue was sent for histopathological examination which showed histiocytes in the cystic spaces and a wall composed of vascularized connective tissue. The patient had an uneventful postoperative course with no complications and recurrence over 6 months.

Discussion

Although the standard treatment of ranula still remains controversial, [8] a variety of surgical procedures have been quoted in the literature ranging from simple aspiration to complete or partial excision of the ranula and/or the sublingual salivary gland, at times involving the submandibular salivary gland. [9] They include: marsupialisation, dissection, cryotherapy, sclerotherapy, hydro dissection and LASER ablation.

The recurrence rate varies according to the procedure performed. [8] Yoshimura et al compared 3 methods of ranula treatment in 27 patients, with a recurrencerate of 25% while excising the ranula only, 36% with marsupialization, and 0% with ranula and ipsilateral sublingual gland excision. [5] In the present case, excision of the ranula was done along with the ipsilateral sublingual gland excision. Crysdale et al reported that the incidence of recurrence after conventional marsupialization of ranulas or pseudo cysts of the oral floor was in the range 61-89 % and so lesions larger than 1 cm should be treated by excision of the sublingual gland. [10] Pandit RT et al [2] showed a 95.5% success rate in the treatment of ranulas by sublingual gland excision with no long-term complications. Bridger et al., suggested this treatment for all ranulas by excising the sublingual gland regardless of their size.[11]

It has been reported that removal of the ipsilateral sublingual gland has potential morbidity, most notably, injuryto the lingual nerve with subsequent numbness,injury to Wharton’s duct with the possibilityof obstructive sialadenitis, and ductal laceration causing salivary leakage. [12]

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Figure 1:

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Figure 1. The above flow chart represents percentage of patients having different types of mental foramen based on gender. The study shows highernumber of male patients havecontinuous type. Whereas female patients predominantly have separate type mental foramen.

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Figure 2:

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Figure 2. The above flow chart represents percentage of patients having different types of mental foramen based on age as factor of consideration. The study divides patients into two different groups I.e, 18-25 years(GroupA) and 26 to 50 years(Group B). As for as Group A and group B is concern higher number of patients have continuous type of mental foramen.

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Figure 3:

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Figure 3. The above flow chart represents position of mental foramen. As study shows Mental foramen largely resides near Position C for both gender.

Conclusion

Excisionof both simple and plunging ranulas along with the sublingual gland can be considered as a safe an effective treatment option. In the present case recurrence of the ranula did not occur even after 6 months. Hence the removal sublingual gland can prevent recurrence by removing the origin of the ranula.