ranula_clinical features and management.pptx

management of ranula

1. Ranula: Clinical Features & Management Dr Priyadarshini Lenka 2 nd year JR , OMFS

2. PREVIOUS YEAR QUESTION RANULA (2021) – 10 MARKS

3. Outline Definition & Types Epidemiology Clinical Features Investigations & Diagnosis Management Options (conservative to surgical) Complications & Prognosis CONCLUSION References

4. What is a Ranula? Ranula is a mucous extravasation cyst arising from the sublingual salivary gland is a type of mucocele found on the floor of the mouth. mucus extravasation cyst > mucus retention cyst. The term derives from Latin “rana” (frog), as its bluish, translucent swelling under the tongue resembles a frog’s underbelly. Simple (Oral) Ranula Confined to the floor of mouth under the tongue, typically measuring 1-3cm in diameter Plunging Ranula Extends beyond the mylohyoid muscle into the neck, creating cervical swelling

5. Epidemiology Ranulas are rare lesions , accounting for ~6% of all oral sialocysts Reported prevalence: ~0.2 cases per 1000 persons in the general population Peak incidence: children and young adults , most common in 2nd–3rd decades of life No strong gender predilection, though some studies note a slight female predominance Oral ranula more common than plunging ranula Plunging ranula : higher prevalence reported in Asian populations; incidence ~ 2.4 per 100,000 person-years in South Auckland study

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7. Clinical features: ORAL RANULA Appearance: Translucent/bluish, dome-shaped, fluctuant, “frog belly” Size: 1–3 cm Location: Unilateral, lateral to frenulum Symptoms: Painless, discomfort if large; may affect speech, swallowing, mastication, respiration Fluctuation Test: Positive, compressible, non-blanching Transillumination: Positive, cystic

8. PLUNGING RANULA / CERVICAL RANULA Appearance: Soft, fluctuant, painless, submandibular mass Size: Variable, may be large Symptoms: Usually asymptomatic; fullness/discomfort; non-mobile with swallowing Location: Below mylohyoid, extends into neck  May extend into Submental / contralateral neck Nasopharynx Retropharynx Upper mediastinum

9. Investigations Clinical exam often diagnostic for oral ranula Ultrasound : cystic lesion, useful in children Aspiration : mucinous fluid with high amylase; FNAC may help exclude other cysts CT/MRI : define extent, relation to mylohyoid for plunging ranula , “tail sign” connecting it to the sublingual space (pathognomonic).

10. Differential Diagnosis Mucocele associated with submandibular gland, dermoid/epidermoid cyst, lymphangioma, Thyroglossal duct cyst, branchial cleft cyst (for neck masses) Sialadenitis or neoplasm (less likely)

11. Management 1 Observation Small, asymptomatic cases - rare spontaneous resolution 2 Minimally Invasive - Aspiration, drainage - high recurrence risk (80-90%) , infant<1year 3 Marsupialization unroof cyst and suture edges — simpler but high recurrence (up to ~60-90%) 4 Definitive Surgery Ranula excision with sublingual gland removal - gold standard

12. Marsupialization Techniques Marsupialization is a conservative surgical approach for ranulas, aiming to create a permanent opening for mucus drainage. Simple Marsupialization Procedure: Unroofing the cyst and suturing its edges to the oral mucosa. Recurrence: High rates (14–89%) often due to premature closure from tongue pressure. Indications: Often considered for children, small ranulas (<2 cm), or when diagnosis is uncertain. Techniques: Includes packing of the cyst cavity, meticulous suturing of pseudocyst edges, and micro-marsupialization (multiple 4-0 silk sutures passed through the ranula). Recurrence: Generally lower rates, ranging from 10–43% (averaging around 20%). Aim: To promote epithelisation of the cyst lining, thereby preventing closure and facilitating continuous drainage. Modified Marsupialization Techniques: Includes packing of the cyst cavity, meticulous suturing of pseudocyst edges, and micro-marsupialization (multiple 4-0 silk sutures passed through the ranula). Post-operative gauze packing for 7–10 days can reduce recurrence to 10–12%.

13. Surgical management Excision of fibrous capsule and the entire sublingual gland (from which it arises) is the most predictable approach . 1.Transoral approach Complete sublingual gland removal with ranula Lowest recurrence rates (less than 5%) Careful preservation of Wharton's duct and lingual nerve.

14. Plunging ranulas are best approached through a transcutaneous incision in the submental triangle. This access will allow removal of the ranula directly and permit repair of the mylohyoid muscle. 2. Transcervical approach

15. Sclerotherapy Sclerosing agents (bleomycin, OK-432) used experimentally for ranulas and plunging ranulas (PR). OK-432 collapses pseudocyst wall and promotes adhesion in Plunging ranula. Study of 32 PR cases: 31 (97%) showed marked lesion size reduction after OK-432 injection. (multiple injections) About 50% experienced transient local pain or fever, resolving within days. Sclerotherapy considered safe and potentially curative; can be used as primary treatment before surgery. Rho MH et al. OK-432 Sclerotherapy of Plunging Ranula., Goodson AM et al. Minimally invasive treatment of oral ranulae . 2015.

16. Complications & Prognosis Complications : recurrence , infection , lingual nerve or Wharton's duct injury after gland excision Prognosis: excellent with appropriate definitive management; recurrence reduced by gland removal

17. The study established clear hierarchy of treatment effectiveness based on complication rates: Most Effective (Lowest Complication Rates): • Transoral sublingual gland excision alone : 3% total complication rate • Transoral sublingual gland + ranula excision : 12% total complication rate Moderately Effective: • Marsupialization : 24% total complication rate • Transcervical sublingual gland + submandibular gland + ranula excision : 33% total complication rate Least Effective (Highest Complication Rates): • OK-432 sclerotherapy : 49% total complication rate • Aspiration alone : 82% total complication rate

18. Conclusion Recurrence: Most common complication (63% of 151 cases). Higher when sublingual gland preserved: aspiration 82%, OK-432 49%, marsupialization 24%. Sublingual gland excision: 0–2% recurrence. Surgical approach: Plunging ranulas: transoral approach better than cervical. Combined transoral-cervical: 37% complication vs 3% for transoral alone. Recommendations: Ranulas are pseudocysts; excision of ranula unnecessary. Sublingual gland excision sufficient; avoid aggressive surgery to prevent nerve injury. Cervical approaches for plunging ranulas not recommended. Marsupialization is an acceptable first-line treatment for oral ranulas despite higher recurrence.

19. References Marx RE, Stern D. Oral and Maxillofacial Pathology: A Rationale for Diagnosis and Treatment. 2nd ed. Hanover Park, IL: Quintessence; 2003. Chapter 9, pp. 445–455. StatPearls : Mucocele and Ranula. 2023. (NCBI Bookshelf). McGurk M. Management of the ranula. J Oral Maxillofac Surg. 2007. Rho MH et al. OK-432 Sclerotherapy of Plunging Ranula. (PMC article). Goodson AM et al. Minimally invasive treatment of oral ranulae . 2015. Medscape: Ranulas and Plunging Ranulas Treatment & Management. 2023.

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21. Management Overview Observation: small/asymptomatic lesions may be observed Conservative: aspiration (temporary), marsupialization (high recurrence) Definitive: excision of sublingual gland ± ranula removal (lowest recurrence) Minimally invasive: sclerotherapy (OK-432, bleomycin) increasingly used

22. Surgical Techniques Marsupialization: unroof cyst and suture edges — simpler but high recurrence (up to ~60-90%) Excision of ranula with sublingual gland removal (intraoral): definitive treatment with low recurrence Cervical approaches reserved for large plunging ranulas or when neck component predominates

23. Suggested Management Algorithm Oral ranula, small/asymptomatic → observe or marsupialize (if needed) Oral ranula, symptomatic or recurrent → intraoral excision of sublingual gland ± ranula Plunging ranula → consider sclerotherapy (OK-432) or sublingual gland excision ± cervical drainage depending on extent Recurrent cases → re-evaluate imaging; definitive gland removal usually required