Ranulas and Plunging Ranulas

Ranulas and Plunging Ranulas

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The term ranula is derived from the Latin word rana, meaning frog, and describes a blue, translucent swelling in the floor of the mouth reminiscent of the underbelly of a frog. The lesions most often appear early in a patient’s life, ie, in the first, second, or third decade. Reported ranulas usually exist in association with oral mucoceles. Ranulas may be classified based on their site of presentation into oral, plunging, or mixed lesions. Oral lesions are confined to the floor of mouth. Plunging ranulas occur less commonly than the oral form.

Hippocrates described ranulas and thought that they were secondary to inflammation. Paré thought that ranulas may represent descent of brain or pituitary matter.

An image depicting a typical ranula can be seen below.

Imaging options for ranula assessment include computed tomography (CT) scanning, ultrasonography, and magnetic resonance imaging (MRI). A variety of surgical approaches exist in the treatment of ranulas, including marsupialization, excision, and removal of the sublingual gland.

Ranulas occur infrequently and tend to present early in life, most often in the first, second, or third decade.

The reported male-to-female ratio is 1:1.3, without significant side preference.

Congenital ranulas may arise secondary to an imperforate salivary duct or ostial adhesion. These are quite rare and have been known to spontaneously resolve. [1]

Posttraumatic ranulas arise from (presumed) trauma to the sublingual gland, leading to mucus extravasation and formation of a pseudocyst. The more appropriate term for this may be mucus extravasation reaction (MER).

Plunging ranulas generally appear in conjunction with oral ranulas, although in rare cases they arise independently, without the oral component. Other terms for plunging ranula include deep, diving, cervical, and deep plunging ranula, as well as oral ranula with cervical extension. These lesions are characterized by mucus extravasation, with extension below the mylohyoid muscle and visible extraoral neck swelling. A congenital dehiscence in the mylohyoid muscle has been suggested as an etiology. [2]

Ranulas can form as a result of partial obstruction of a sublingual duct, leading to formation of an epithelial-lined retention cyst. This is unusual, occurring in less than 10% of all ranulas.

Ranulas can also result from trauma leading to the formation of extravasated saliva. Experimentally, partial severance or ligation of the sublingual duct leads to ranula formation, whereas ligation of the submandibular duct does not. The ligation of the parotid duct ultimately leads to atrophy. The difference lies in the fact that the sublingual gland secretes continuously in the interdigestive period and appears to be able to secrete against a gradient, whereas the other two major salivary glands secrete only in response to stimuli such as eating. Therefore, with trauma, if the sublingual duct is obstructed, secretory back pressure builds and acini rupture, leading to mucus extravasation. Alternately, trauma causing direct damage to the duct or acini can lead to mucus extravasation, with subsequent pseudocyst formation.

Plunging ranulas arise in the neck by one of 3 mechanisms:

The sublingual gland may project through the mylohyoid, or an ectopic sublingual gland may exist on the cervical side of the mylohyoid. This explains most plunging ranulas that exist without an oral component.

The pseudocyst may penetrate through the mylohyoid. Up to 27-45% of mylohyoid muscles in cadavers are found to be dehiscent, usually in the anterior two thirds of the muscle. These sites of dehiscence provide a route of egress for the cyst. In some instances, surgical trauma from initial ranula operations may scar or fibrose the superior surface of a ranula. When the ranula recurs, the path of least resistance is through a dehiscent mylohyoid, and a plunging ranula forms when only a simple ranula was present initially. Up to 44% of all plunging ranulas are iatrogenically induced in this manner.

A duct from the sublingual gland may join the submandibular gland or its duct, allowing ranulas to form in continuity with the submandibular gland. Therefore, the ranula accesses the neck from behind the mylohyoid muscle.

A ranula is most commonly observed as a bluish cyst located below the tongue as seen in the images below. It may fill the mouth and raise the tongue. Typically, these are painless masses that do not change in size in response to chewing, eating, or swallowing. Occasionally, pain may be involved. (See the images below.)

Plunging ranulas can manifest as neck swelling in conjunction with, or independent of, a floor-of-mouth cyst. Occasionally, squeezing the mass causes swelling in the floor-of-mouth cyst. Most reported plunging ranulas are 4-10 cm in size and are usually found in the submandibular space. They have been reported to extend into the submental region, the contralateral neck, the nasopharynx up to the skull base, the retropharynx, and even into the upper mediastinum. [3, 4]

See Surgical therapy.

The sublingual gland lies against the sublingual depression of the mandible and directly on the mylohyoid. The submandibular duct (Wharton duct) and the lingual nerve lie posterior and medial to the gland. The genioglossus muscle is medial to these structures. No posterior fascial limits to the sublingual space exist, which allows lesions to exit the sublingual space and enter into the submandibular or parapharyngeal space.

The sublingual gland is unique among the major salivary glands in that it lacks a true capsule and is more consistent with a significant conglomeration of many smaller glands. The sublingual gland is drained by a collective of minor ducts known as the ducts of Rivinus (especially anteriorly), which open into the floor of the mouth, usually along the sublingual fold. At times, several ducts may coalesce and form a more substantive duct termed the Bartholin duct, which often joins the submandibular duct proximal to the sublingual caruncle.

Although some have advocated surgical management of congenital ranulas, recent literature supports observation in asymptomatic patients. Many congenital ranulas resolve on their own and do not require surgical intervention.

Recurrence of the ranula is possible despite surgical excision. Some ranulas have been noted to resolve spontaneously.

Steelman R, Weisse M, Ramadan H. Congenital ranula. Clin Pediatr (Phila). 1998 Mar. 37(3):205-6. [Medline].

Nguyen BN, Malone BN, Sidman JD, Barnett Roby B. Excision of sublingual gland as treatment for ranulas in pediatric patients. Int J Pediatr Otorhinolaryngol. 2017 Jun. 97:154-6. [Medline].

Effat KG. Acute presentation of a plunging ranula causing respiratory distress: case report. J Laryngol Otol. 2012 Aug. 126(8):861-3. [Medline].

Jain R, Morton RP, Ahmad Z. Diagnostic difficulties of plunging ranula: case series. J Laryngol Otol. 2012 May. 126(5):506-10. [Medline].

Coit WE, Harnsberger HR, Osborn AG. Ranulas and their mimics: CT evaluation. Radiology. 1987 Apr. 163(1):211-6. [Medline].

Sumi M, Izumi M, Yonetsu K. Sublingual gland: MR features of normal and diseased states. AJR Am J Roentgenol. 1999 Mar. 172(3):717-22. [Medline].

Jain P, Jain R, Morton RP, Ahmad Z. Plunging ranulas: high-resolution ultrasound for diagnosis and surgical management. Eur Radiol. 2010 Jun. 20(6):1442-9. [Medline].

Fukase S, Ohta N, Inamura K. Treatment of Ranula with Intracystic Injecton of the Streptococcal Preparation OK-432. Ann Otol Rhinol Laryngol. 2003. 112(3):214-20. [Medline].

Ikarashi T, Inamura K, Kimura Y. Cystic lymphangioma and plunging ranula treated by OK-432 therapy: a report of two cases. Acta Otolaryngol Suppl. 1994. 511:196-9. [Medline].

Ohta N, Fukase S, Suzuki Y, Kurakami K, Aoyagi M, Kakehata S. OK-432 treatment of ranula extending to the parapharyngeal space. Acta Otolaryngol. 2014 Feb. 134 (2):206-10. [Medline].

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Baurmash HD. Marsupialization for treatment of oral ranula: a second look at the procedure. J Oral Maxillofac Surg. 1992 Dec. 50(12):1274-9. [Medline].

Woo SH, Chi JH, Kim BH, Kwon SK. Treatment of intraoral ranulas with micromarsupialization: clinical outcomes and safety from a phase II clinical trial. Head Neck. 2015 Feb. 37 (2):197-201. [Medline].

Morton RP, Bartley JR. Simple sublingual ranulas: pathogenesis and management. J Otolaryngol. 1995 Aug. 24(4):253-4. [Medline].

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 Apr. 52(4):370-2. [Medline].

Shimm DS, Berk FK, Tilsner TJ. Low-dose radiation therapy for benign salivary disorders. Am J Clin Oncol. 1992 Feb. 15(1):76-8. [Medline].

Yoshimura Y, Obara S, Kondoh T. A comparison of three methods used for treatment of ranula. J Oral Maxillofac Surg. 1995 Mar. 53(3):280-2; discussion 283. [Medline].

Zhao Y, Jia Y, Chen X. Clinical Review of 580 Ranulas. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2004. 98(3):281-7. [Medline].

Yang Y, Hong K. Surgical results of the intraoral approach for plunging ranula. Acta Otolaryngol. 2014 Feb. 134 (2):201-5. [Medline].

Cochran CS, Zhou CQ, DeFatta RJ, Adelson RT. An innovative method of facilitating ranula excision with methylene blue injection. Ear Nose Throat J. March 2006. 85(3):159, 163. [Medline].

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Ali MK, Chiancone G, Knox GW. Squamous cell carcinoma arising in a plunging ranula. J Oral Maxillofac Surg. 1990 Mar. 48(3):305-8. [Medline].

Danford M, Eveson JW, Flood TR. Papillary cystadenocarcinoma of the sublingual gland presenting as a ranula. Br J Oral Maxillofac Surg. 1992 Aug. 30(4):270-2. [Medline].

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Brent Golden, DDS, MD Assistant Professor, Department of Oral and Maxillofacial Surgery, University of North Carolina at Chapel Hill School of Dentistry; Adjunct Assistant Professor, Department of Pediatrics, University of North Carolina at Chapel Hill School of Medicine

Brent Golden, DDS, MD is a member of the following medical societies: American Association of Oral and Maxillofacial Surgeons, American Cleft Palate-Craniofacial Association, American Dental Association

Disclosure: Nothing to disclose.

Amelia F Drake, MD ND Fischer Distinguished Professor of Otolaryngology, Executive Associate Dean of Academic Programs, Director, Craniofacial Center, Department of Otolaryngology-Head and Neck Surgery, University of North Carolina at Chapel Hill School of Medicine

Amelia F Drake, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Otolaryngology-Head and Neck Surgery, American Cleft Palate-Craniofacial Association, American Society of Pediatric Otolaryngology, North Carolina Medical Society

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Peter S Roland, MD Professor, Department of Neurological Surgery, Professor and Chairman, Department of Otolaryngology-Head and Neck Surgery, Director, Clinical Center for Auditory, Vestibular, and Facial Nerve Disorders, Chief of Pediatric Otology, University of Texas Southwestern Medical Center; Chief of Pediatric Otology, Children’s Medical Center of Dallas; President of Medical Staff, Parkland Memorial Hospital; Adjunct Professor of Communicative Disorders, School of Behavioral and Brain Sciences, Chief of Medical Service, Callier Center for Communicative Disorders, University of Texas School of Human Development

Peter S Roland, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Otolaryngic Allergy, American Academy of Otolaryngology-Head and Neck Surgery, American Auditory Society, American Neurotology Society, American Otological Society, North American Skull Base Society, Society of University Otolaryngologists-Head and Neck Surgeons, The Triological Society

Disclosure: Received honoraria from Alcon Labs for consulting; Received honoraria from Advanced Bionics for board membership; Received honoraria from Cochlear Corp for board membership; Received travel grants from Med El Corp for consulting.

Arlen D Meyers, MD, MBA Professor of Otolaryngology, Dentistry, and Engineering, University of Colorado School of Medicine

Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American Head and Neck Society

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Cerescan;RxRevu;Cliexa;Preacute Population Health Management;The Physicians Edge<br/>Received income in an amount equal to or greater than $250 from: The Physicians Edge, Cliexa<br/> Received stock from RxRevu; Received ownership interest from Cerescan for consulting; for: Rxblockchain;Bridge Health.

Daniel J Kelley, MD Consulting Staff, Eastern Shore ENT and Allergy Associates and Peninsula Regional Medical Center

Daniel J Kelley, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Head and Neck Society, The Triological Society

Disclosure: Nothing to disclose.

Gregory C Allen, MD Assistant Professor, Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine

Gregory C Allen, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Academy of Pediatrics, American Cleft Palate/Craniofacial Association, American College of Surgeons, American Laryngological Rhinological and Otological Society, American Medical Association, Christian Medical & Dental Society, and Colorado Medical Society

Disclosure: Nothing to disclose.

Ryan L Van De Graaff, MD Consulting Staff, Southwest Idaho Ear, Nose and Throat

Ryan L Van De Graaff, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Otolaryngology-Head and Neck Surgery, and American Medical Association

Disclosure: Nothing to disclose.

Ranulas and Plunging Ranulas

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