Ranula – A Case Report

Abstract:
Ranula by definition is a mucous filled cavity, a mucocele, in
the floor of the mouth in relation to the sub lingual gland. The name
“ranula” has been derived from the latin word “Rana” which means
“Frog”. The swelling resembles a frog's translucent under belly or air
sacs. Ranulas are characteristically large (>2cm) and appear as a tense
fluctuant dome shaped swelling, commonly in the lateral floor of the
oral cavity. This paper highlights a case report of ranula in the floor of
the mouth that has been successfully treated by excision of the ranula
along with the sublingual gland.
Key words :
Ranula,Sublingual Gland .
1 2 3 4
Dr. , Dr. , Dr. , Dr. Suman Jaishankar Manimaran Kannan Christeffi Mabel
CASE REPORT
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Reader
Dept. of Oral Medicine and radiology
Professor and H O D
Reader
Dept Of Oral and Maxillofacial Surgery
Senior Lecturer
Dept. of Oral Medicine and radiology
K.S.R. Institute of Dental Science and Research,
Tiruchengode
Address for correspondence :
Dr. Suman Jaishankar M.D.S.,
Reader, Dept of oral medicine and radiology,
K.S.R. Institute of Dental Science and Research,
Thokkavady, Thiruchengode Tk - 637215,
Namakkal Dt, Tamil Nadu, India.
e-mail : sjjsin@yahoo.co.in
Introduction:
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Ranula is reported by Hippocrates and celcius.
Theoretically, the ranula formation is excretory duct rupture
followed by extravasation and accumulation of saliva into
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the surrounding tissue. The accumulation of mucous into
the surrounding connective tissue forms a pseudocyst that
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lacks an epithelial lining . The analysis of the saliva reveals
a high protein and amylase concentration consistent with
secretions from the mucinous acini in the sublingual gland.
The high protein content may produce a very intense
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inflammatory reaction and mediate pseudocyst formation.
Many methods of treatment for ranulas have been
described in literature, including excision of ranula only,
excision of ranula and the ipsilateral sublingual gland,
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marsupialisation and cryosurgery.
The definitive treatment is now considered to be
surgical excision of the ipsilateral sublingual gland, which is
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supported by recent studies.
Case Report:
A 22 year old male patient reported to the
outpatient department with a chief complaint of painless
swelling below the tongue on the right side, for the past one
month. History revealed that the swelling has gradually
increased in size to the present size. No history of any pain
was reported. His past history revealed that he had
undergone endodontic treatment in 46.
On examination, a 1x 2 cm bluish fluctuant
swelling was seen in the floor of the mouth adjacent to 46,
47 region. The swelling was nontender, soft in consistency
and no discharge was elicited.
On correlating the clinical findings, the case was
provisionally diagnosed as “ranula”. The patient was
subjected to radiographic examination, which revealed no
evidence of obstruction. After other routine preoperative
investigation, excision of ranula along with the sublingual
gland was carried out under local anaesthesia. Sutures
were placed. Patient was kept under observation. He
developed paresthesia and was prescribed Tab.Renerve (1
O.D.). The patient was followed up every week. Paresthetic
sensation gradually reduced.
JIADS VOL -1 Issue 3 July - September,2010 |52|
Discussion:
Ranula is a mucous containing swelling that occurs
in the floor of the mouth. It usually presents as a well
circumscribed, soft, bluish cyst covered by a thin layer of
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epithelium.
The causes of ranula formation were thought to be
trauma or surgery to the floor of the mouth, neck region
which may rupture the sub lingual gland acini or cause
obstruction of the sublingual gland ducts which results in
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mucous extravasation.
Ranula can be classified into two groups, simple
(intra oral) and the plunging ( Cervical) type. Simple ranula
is much more common than plunging type. A simple ranula
represents a localised collection of mucous within the floor
of the mouth. In plunging ranula, the mucous collection is in
the sub mandibular and sub mental space of the neck with
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or without an associated intraoral collection.
The possibility of a plunging ranula should be
considered in a patient with a painless cervical swelling that
gradually increases in size, particularly if there is a history of
oral trauma, including dental or other oral surgical
procedures.
The diagnosis of ranula is based principally on the
clinical examination and sometimes on computerised
tomographic or magnetic resonance imaging findings for
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the plunging lesion. If there is a doubt about the diagnosis,
aspiration of the mucous from the lesion and a laboratory
determination of amylase content should make the
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diagnosis of ranula obvious.
The differential diagnosis of ranula includes
abcess, dermoid cyst, and vascular lesions. The differential
diagnosis of a plunging ranula includes branchial cyst,
thyroglossal duct cyst, epidermal cyst, cystic hygroma,
arteriovenous malformation, lymphadenopathy, abcess or
soft tissue tumours.
There are several different methods of treatment
for ranulas. These include excision of the ranula via an
intraoral or cervical approach, marsupialisation, intra oral
excision of the sublingual gland and drainage of the lesion,
and excision of the lesion with sublingual gland.
Newer treatment modalities like OK-432 were
tried on some patients. But, since the drug is not widely
available and adverse effects like fever and pain at the
injection site were encountered, this drug never gained
popularity. Another innovative, simple nonsurgical method
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was the use of botulinum toxin type A to treat ranulas.
Sialoendoscopy is a promising new method for use
in diagnosis, treatment and postoperative management of
sialadenitis, sialolithiasis and other obstructive salivary
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gland diseases.
Conclusion
Effective treatment of salivary gland disorders
requires accurate diagnosis of the specific disease. Newer
advancements in the field of imaging, aid the clinician in
making a proper diagnosis. Since injury to the lingual nerve
and sublingual duct are potential complications associated
with surgical procedures, the quest for alternative treatment
modalities continues.
References
1. Cedric A. Quick; Seth H. Lowell. Ranula and the Sublingual Salivary
Glands. Arch Otolaryngol. 1977; 103(7):397-400.
2. Morton RP, Bartley JR. Simple sublingual ranulas: pathogenesis and
management. J Otolaryngol. 1995;24(4):253-4.
3. Bronstein SL, Clark MS. Sublingual gland salivary fistula and sialocele.
Oral Surg Oral Med Oral Pathol. 1984;57(4):357-61.
4. Zhi K, Wen Y, Ren W, Zhang Y. Management of infant ranula. Int J Pediatr
Otorhinolaryngol. 2008;72(6):823-6
5. Yoshimura Y, Obara S, Kondoh T, Naitoh S. A comparison of three methods
used for treatment of ranula. J Oral Maxillofac Surg. 1995; 53(3):280-2;
discussion 283.
6. Zhao YF, Jia J, Jia Y. Complications associated with surgical management of
ranulas. J Oral Maxillofac Surg. 2005; 63(1):51-4.
7. David A. Lloyd, Mohamed Elgabrun and Helen Carty. Plunging (cervical)
ranula. Pediatr Surg Int. 1995; 10(2-3): 144-145.
8. Mahadevan M, Vasan N. Management of pediatric plunging ranula. Int J
Pediatr Otorhinolaryngol. 2006; 70(6):1049-54.
9. Zhao YF, Jia Y, Chen XM, Zhang WF. Clinical review of 580 ranulas. Oral
Surg Oral Med Oral Pathol Oral Radiol Endod. 2004; 98(3):281-7.
10. 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(1):41-2.
11. Nahlieli O, Nakar LH, Nazarian Y, Michael DT. Sialendoscopy: A new
approach to Salivary gland obstructive pathology. J Am Dent Asso. 2006;
137(10):1394-1400.
JIADS VOL -1 Issue 3 July - September,2010 |53|
Ranula - A Case Report Suman Jaishankar, Manimaran, Kannan & Christeffi Mabel

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