- Email: [email protected]
Treatment outcomes of the intraoral approach for a simple ranula
Accepted Manuscript Treatment outcomes of intraoral approach for simple ranula Dong Hoon Lee, MD, Tae Mi Yoon, MD, Joon Kyoo Lee, MD, Sang Chul Lim, MD PII:
S2212-4403(15)00038-3
DOI:
10.1016/j.oooo.2015.01.007
Reference:
OOOO 1111
To appear in:
Oral Surgery, Oral Medicine, Oral Pathology and Oral Radiology
Received Date: 6 November 2014 Revised Date:
15 January 2015
Accepted Date: 23 January 2015
Please cite this article as: Lee DH, Yoon TM, Lee JK, Lim SC, Treatment outcomes of intraoral approach for simple ranula, Oral Surgery, Oral Medicine, Oral Pathology and Oral Radiology (2015), doi: 10.1016/ j.oooo.2015.01.007. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
1
ACCEPTED MANUSCRIPT
Treatment outcomes of intraoral approach for simple ranula
RI PT
Dong Hoon Lee, MD, Tae Mi Yoon, MD, Joon Kyoo Lee, MD, and Sang Chul
SC
Lim, MD
Department of Otolaryngology-Head and Neck Surgery, Chonnam National
Hwasun, South Korea
M AN U
University Medical School; and Chonnam National University Hwasun Hospital,
TE D
Running title: Surgery for simple ranula
Address for correspondence:
Joon Kyoo Lee, MD, PhD
EP
Department of Otolaryngology-Head and Neck Surgery Chonnam National University Medical School and Hwasun Hospital,
AC C
160 Ilsimri, Hwasun, Jeonnam, South Korea 519-809 Tel: +82-61-379-8190 Fax: +82-61-379-7761 E-mail: [email protected]
No acknowledgements have been disclosed for this article. No sponsorships or competing interests have been disclosed for this article.
2
ACCEPTED MANUSCRIPT
Word count for the abstract: 190 Word count for the complete manuscript: 1493
Number of figures: 0 Number of tables: 2
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EP
TE D
M AN U
SC
Number of supplementary elements: 0
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Number of reference: 16
3
ACCEPTED MANUSCRIPT
ABSTRACT OBJECTIVE: The study sought to determine the optimum surgical treatment of
RI PT
simple ranula and analyzed the clinical characteristics and treatment outcomes of simple ranula in our hospital.
METHODS: A retrospective review was performed to evaluate patients with a
SC
diagnosis of simple ranula at Chonnam National University Hwasun Hospital
M AN U
from November 2007 to August 2013. Clinical data of simple ranula that were reviewed included sex, age, symptoms, duration of symptoms, location and size of lesion, surgical procedures, complications, recurrence, and follow-up.
TE D
RESULTS: The 24 patients comprised 10 males and 14 females. Sixteen patients (66.7%) had not prior treatment history. Eight patients had undergone
EP
previous treatment that included Picivanyl injection sclerotherapy, incision and drainage, and micromarsupialization. The recurrence of simple ranula after the
AC C
excision of ranula and sublingual gland was found in only one case (4.2%) among 24 patients. In eight patients who had undergone previous treatment, there was no recurrence after the excision of ranula and sublingual gland. There were no major complications and recurrences for recurrent simple ranula. CONCLUSIONS: Excision of ranula and sublingual gland via intraoral approach is the optimum treatment for simple ranula, even if recurrent simple ranula.
4
ACCEPTED MANUSCRIPT
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SC
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Key Words: Ranula, Sublingual gland, Recurrent, Excision
5
ACCEPTED MANUSCRIPT
INTRODUCTION Ranula is a cystic lesion located on the floor or the mouth that arises from
RI PT
trauma or obstruction of the excretory duct of the sublingual gland.1-4 According to the location, ranulas are classified into three groups: the sublingual type,
SC
sublingual-submandibular type, and submandibular type.4,5 The sublingual ranula (simple ranula) is a mucus retention cyst or more commonly a mucus
M AN U
extravasation pseudocyst confined to the floor of the mouth.1 Plunging ranula or cervical ranula (sublingual-submandibular type, submandibular type) appears as a submandibular mass without visible intraoral involvement.1,4
TE D
There were various diagnostic methods of a ranula ranging from clinical observation alone to fine needle aspiration and imaging.3 We have considered
EP
clinical observation and computed tomography (CT) to be a valuable and
AC C
sufficient technique for the assessment of ranula. Although most ranulas are currently treated by surgery, the standard treatment of ranula is still controversial.6 In simple ranula, the lesions are easily observed and are usually treated by incision and drainage, marsupialization, and sclerotherapy at a local hospital. However, in some cases, the simple ranulas recur, necessitating referral to a tertiary medical center.
6
ACCEPTED MANUSCRIPT
Presently, we sought to determine the optimum surgical treatment of simple ranula and also analyzed the clinical characteristics and treatment outcomes of
AC C
EP
TE D
M AN U
SC
RI PT
simple ranula in our hospital.
7
ACCEPTED MANUSCRIPT
MATERIALS and METHODS After obtaining approval from the Institutional Review Board of Chonnam
RI PT
National University Hwasun Hospital, a retrospective review was performed to evaluate patients with a diagnosis of simple ranula at the hospital’s Department
SC
of Otolaryngology-Head and Neck Surgery from November 2007 to August
M AN U
2013. Twenty-four patients with a diagnosis of simple ranula were identified based on their medical records. Patients with plunging ranula were excluded. Clinical data of simple ranula were reviewed including sex, age, symptoms, duration of symptoms, location and size of lesion, surgical procedures,
TE D
complications, recurrence, and follow-up. Eighteen of the 24 patients underwent preoperative computed tomography
EP
(CT) to assess the extent of the simple ranula. All 24 patients had simple ranula
AC C
surgically removed with an intraoral approach under general anesthesia. A descriptive analysis was performed for each of the variables, and correlation determined using the chi-square test. Statistical significance was considered for p < 0.05.
8
ACCEPTED MANUSCRIPT
RESULTS This group of 24 patients included 10 (41.7%) males and 14 (58.3%) females.
RI PT
The age of the patients ranged between 4 and 58 years with a mean of 21.0 ± 16.4 years. All patients presented with an asymptomatic enlarging mass within
SC
the mouth floor. The duration of symptoms ranged from 0.2 - 60 months with a
M AN U
mean of 5.5 ± 11.8 months. Eight ranulas were located on the right side (33.3%) and 16 on the left (66.7%). The size of simple ranula varied between 1 and 3 cm in 10 cases, four cases were < 1 cm, and 10 cases were > 3 cm. Sixteen patients (66.7%) showed no treatment history before visiting our clinic
TE D
(Table 1). The remaining 8 patients had undergone previous treatment by another hospital. However, the simple ranula recurred and the patients were
EP
referred to our clinic. Two patients had undergone Picivanyl injection
AC C
sclerotherapy. Four patients had a history of incision and drainage, one patient had undergone micromarsupialization. Another patient underwent three incision and drainage procedures and three micromarsupializations at a local hospital. Eighteen patients (75%) underwent preoperative CT to assess the extent of the simple ranula (Table 2). All patients with simple ranulas ≤ 1 cm were not diagnosed by preoperative CT scan, while all patients with simple ranulas
9
ACCEPTED MANUSCRIPT
exceeding 1 cm were diagnosed by preoperative CT scan. The size of lesions and diagnosis of lesions by CT scan were statistically significantly different (p =
RI PT
0.007).
All patients except one underwent removal of ranula and sublingual gland.
SC
One patient underwent only ranula excision without removal of sublingual gland,
M AN U
because the size of lesion was very small. All eight patients with recurrent simple ranula after previous treatment by another hospital were treated by excision of the ranula and sublingual gland.
There were no postoperative complications including infection and bleeding.
TE D
One patient with a history of sclerotherapy presented a partial numbness of tongue sensation that resolved within 2 months after surgery. There was no
EP
transient or permanent hypoglossal nerve palsy in this study.
AC C
The mean follow-up was 44.1 ± 17.0 months (range 15 - 82 months). Twelve months after the surgery, recurrence was found in one case (4.2%). The patient had no previous treatment history and had a huge (4.8 x 2.2 cm) sized ranula. According to the operation record, ranula was connected to the deeper portion of sublingual space, and surgeon could not be sure to remove all ranula and sublingual gland. Therefore, the reasons of recurrence were considered
10
ACCEPTED MANUSCRIPT
residual ranula cystic wall and sublingual gland tissue. The patient wanted the
AC C
EP
TE D
M AN U
SC
RI PT
re-operation at another hospital and was referred.
11
ACCEPTED MANUSCRIPT
DISCUSSION Ranula occurs in 1 - 10% of cases and has a prevalence of 0.2 cases per
RI PT
1000 persons.3 Ranulas are generally asymptomatic, but if the size is large, it may affect swallowing, speech, mastication, or breathing.3,7 In this study, all
SC
patients were asymptomatic. The etiology of the ranula is unknown, but has
M AN U
been described in association with the sublingual gland.1,8 It is usually related to trauma to the sublingual gland or the duct and scar formation following this may cause obstruction.3
The diagnosis of ranula is made on clinical and imaging findings.3,9,10 Clinical
TE D
examination provides most of the diagnostic information.1,3 Imaging modalities include ultrasound, CT scan, and magnetic resonance imaging (MRI). CT and
EP
MRI may aid in the preoperative diagnosis and differential diagnosis in some
AC C
cases of plunging ranula.9,10 Some authors suggested that CT and MRI may aid in the preoperative diagnosis but they do not employ either unless the diagnosis is in doubt.1,3 In this study, 18 patients (75%) underwent preoperative CT to assess the extent of the ranula. The size of lesions and diagnosis of lesions by CT scan were statistically significantly different. Therefore, if the size of simple ranula was < 1 cm, the surgeon could refrain from a routine CT scan.
12
ACCEPTED MANUSCRIPT
There are many surgical and non-surgical interventions to treat ranulas.3,11 However, surgery remains the mainstay treatment for simple ranula.3,7,8,9,11 The
sublingual
gland,
incision
and
drainage,
RI PT
wide variety of surgical procedures include ranula excision, excision of marsupialization,
and
SC
micromarsupialization. Incision and drainage should not be performed because
M AN U
of the resulting rapid closure of the wound and recurrence of ranula.11,12 Marsupialization was once considered as the treatment of choice for ranula and is still used.3,7 However, marsupialization is associated with high recurrence rates and extension to plunging ranula.1,2,11,13
TE D
Ranula excision also is associated with high rates of recurrence and is not widely used.4 However, ranula excision may be useful in some cases, such as
EP
superficial and protruding, within a small sized simple ranula.2 In this study, we
AC C
performed only one simple ranula excision that satisfied the aforementioned options. Recurrence did not occur. Since the introduction of micromarsupialization in 1995, the procedure can be easily performed at the outpatient clinic and leads to less discomfort and fewer complications.11,14,15 However, there have been no reported results of efficacy and safety of long-term follow-ups and have not been investigated in studies
13
ACCEPTED MANUSCRIPT
with a large sample size. In this study, there were two patients with recurrence after micromarsupialization before visiting our clinic. In addition, one patient
RI PT
required care at the emergency department after the micromarsupialization because of acute severe swelling of the floor of the mouth. The other patient with
a
recurrent
lesion
despite
multiple
revision
SC
presented
micromarsupializations.
M AN U
While the optimum treatment is still open to debate,6 we believe that ranula removal combined with sublingual gland excision via intraoral approach is the ideal treatment for simple ranula.2,3,4,8 In this study, the recurrence of simple
TE D
ranula after the excision of ranula and sublingual gland was found in only one case (4.2%) among 24 patients. In eight patients with recurrent simple ranula
EP
after previous treatment by another hospital, there was no recurrence after the
AC C
excision of ranula and sublingual gland. Complications associated with procedures for the treatment of ranula include injury to Wharton’s duct, lingual nerve injury, sensory impairment of the tongue, bleeding or hematoma, and wound dehiscence.7,9,16 Excision of the sublingual gland is associated with a major risk of injury to the lingual nerve and Wharton’s duct.9,10 There was no permanent injury to the lingual nerve and Wharton’s duct
14
ACCEPTED MANUSCRIPT
in this study. This study has some limitations due to its small sample size and retrospective
RI PT
review. However, our study strongly suggest that intraoral excision of ranula and sublingual gland can be used an ideal treatment for simple ranula, even if
SC
recurrent simple ranula after previous treatment. Further studies are needed to
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EP
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confirm our results.
15
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CONCLUSIONS Excision of ranula and sublingual gland via the intraoral approach is the ideal
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treatment for simple ranula. Especially, intraoral excision of ranula and sublingual gland provides a 100% success rate in managing recurrent simple
SC
ranula (n=8) after previous treatment with minimal complications. In addition, if
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the size of simple ranula is <1 cm, CT scan is not necessary.
16
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REFERENCES 1. Davision MJ, Morton RP, Mclvor NP. Plunging ranula: clinical observations.
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Head Neck. 1998;20(1):63-68.
2. Morita Y, Sato K, Kawana M, Takahasi S, Ikarashi F. Treatment of ranula –
SC
excision of the sublingual gland versus marsupialization. Auris Nasus Larynx.
M AN U
2003;30(3):311-314.
3. Ghani N, Ahmad R, Rahman RA, Yunus MR, Putra SP, Ramli R. A retrospective study of ranula in two centres in Malaysia. J Maxillofac Oral Surg. 2009;8(4):316-319.
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4. Yang Y, Hong K. Surgical results of the intraoral approach for plunging ranula. Acta Otolaryngol. 2014;134(2):201-205.
EP
5. Woo JS, Hwang SJ, Lee HM. Recurrent plunging ranula treated with OK-
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432. Eur Arch Otorhinolaryngol. 2003;260(4):226-228. 6. Patel MR, Deal AM, Shockley WW. Oral and plunging ranulas: What is the most effective treatment? Laryngoscope. 2009;119(8):1501-1509. 7. Bonet-Coloma C, Minguez-Martinez I, Aloy-Prosper A, Galan-Gil S, Penarrocha-Diago M, Minguez-Sanz JM. Pediatric oral ranula: clinical follow-up study of 57 cases. Med Oral Patol Oral Cir Bucal. 2011;16(2):e158-162.
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8. Huang SF, Liao CT, Chin SC, Chen IH. Transoral approach for plunging ranula – 10 year experience. Laryngoscope. 2010;120(1):53-57.
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9. Sigismund PE, Bozzato A, Schumann M, Koch M, Iro H, Zenk J. Management of ranula: 9 years’ clinical experience in pediatric and adult
SC
patients. J Oral Maxillofac Surg. 2013;71(3):538-544.
M AN U
10. 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):281-287. 11. Woo SH, Chi JH, Kim BH, Kwon SK. Treatment of intraoral ranulas with micromarsupialization: Clinical outcomes and safety (From a Phase II Clinical
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Trial). Head Neck. 2013 Dec 22 [Epub ahead of print]. 12. Crysdale WS, Mendelsohn JD, Conley S. Ranula-mucoceles of the oral
EP
cavity: experience in 26 children. Laryngoscope. 1988;98(3):296-298.
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13. Haberal I, Gocmen H, Samim E. Surgical management of pediatric ranula. Int J Pediatr Otorhinolaryngol. 2004;68(2):161-163. 14. Morton RP, Bartley JR. Simple sublingual ranulas: pathogenesis and management. J Otolaryngol. 1995;24(4):253-254. 15. Delbem AC, Cunha RF, Vieira AE, Ribeiro LL. Treatment of mucus retention phenomena in children by the micro-marsupialization technique: case
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reports. Pediatr Dent. 2000;22(2):155-8.
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EP
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SC
of ranulas. J Oral Maxillofac Surg. 2005;63(1):51-54.
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16. Zhao YF, Jia J, Jia Y. Complications associated with surgical management
1
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Table 1. Previous treatment history. Number of patients (%)
None
16 (66.7)
Incision and drainage
4 (16.7)
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Micromarsupialization
2 (8.3)
SC
Picivanyl injection
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Treatment
1 (4.2) 1 (4.2)
Total
24 (100)
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Incision and drainage, micromarsupialization
1
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Table 2. Preoperative CT scans. Diagnosis by CT scan (%)
< 1 cm
0 / 2 (0)
1 - 3 cm
7 / 7 (100)
> 3 cm
9 / 9 (100)
Total
16 / 18 (88.9)
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EP
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SC
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Size of Ranula (cm)
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Dear Editor-in-Chief,
Excision of ranula and sublingual gland via the intraoral approach is the ideal
is < 1 cm, CT scan is not necessary.
SC
Sincerely yours,
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treatment for simple ranula, especially recurrent simple ranula. If simple ranula
AC C
EP
TE D
M AN U
Lee DH
S2212-4403(15)00038-3
DOI:
10.1016/j.oooo.2015.01.007
Reference:
OOOO 1111
To appear in:
Oral Surgery, Oral Medicine, Oral Pathology and Oral Radiology
Received Date: 6 November 2014 Revised Date:
15 January 2015
Accepted Date: 23 January 2015
Please cite this article as: Lee DH, Yoon TM, Lee JK, Lim SC, Treatment outcomes of intraoral approach for simple ranula, Oral Surgery, Oral Medicine, Oral Pathology and Oral Radiology (2015), doi: 10.1016/ j.oooo.2015.01.007. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
1
ACCEPTED MANUSCRIPT
Treatment outcomes of intraoral approach for simple ranula
RI PT
Dong Hoon Lee, MD, Tae Mi Yoon, MD, Joon Kyoo Lee, MD, and Sang Chul
SC
Lim, MD
Department of Otolaryngology-Head and Neck Surgery, Chonnam National
Hwasun, South Korea
M AN U
University Medical School; and Chonnam National University Hwasun Hospital,
TE D
Running title: Surgery for simple ranula
Address for correspondence:
Joon Kyoo Lee, MD, PhD
EP
Department of Otolaryngology-Head and Neck Surgery Chonnam National University Medical School and Hwasun Hospital,
AC C
160 Ilsimri, Hwasun, Jeonnam, South Korea 519-809 Tel: +82-61-379-8190 Fax: +82-61-379-7761 E-mail: [email protected]
No acknowledgements have been disclosed for this article. No sponsorships or competing interests have been disclosed for this article.
2
ACCEPTED MANUSCRIPT
Word count for the abstract: 190 Word count for the complete manuscript: 1493
Number of figures: 0 Number of tables: 2
AC C
EP
TE D
M AN U
SC
Number of supplementary elements: 0
RI PT
Number of reference: 16
3
ACCEPTED MANUSCRIPT
ABSTRACT OBJECTIVE: The study sought to determine the optimum surgical treatment of
RI PT
simple ranula and analyzed the clinical characteristics and treatment outcomes of simple ranula in our hospital.
METHODS: A retrospective review was performed to evaluate patients with a
SC
diagnosis of simple ranula at Chonnam National University Hwasun Hospital
M AN U
from November 2007 to August 2013. Clinical data of simple ranula that were reviewed included sex, age, symptoms, duration of symptoms, location and size of lesion, surgical procedures, complications, recurrence, and follow-up.
TE D
RESULTS: The 24 patients comprised 10 males and 14 females. Sixteen patients (66.7%) had not prior treatment history. Eight patients had undergone
EP
previous treatment that included Picivanyl injection sclerotherapy, incision and drainage, and micromarsupialization. The recurrence of simple ranula after the
AC C
excision of ranula and sublingual gland was found in only one case (4.2%) among 24 patients. In eight patients who had undergone previous treatment, there was no recurrence after the excision of ranula and sublingual gland. There were no major complications and recurrences for recurrent simple ranula. CONCLUSIONS: Excision of ranula and sublingual gland via intraoral approach is the optimum treatment for simple ranula, even if recurrent simple ranula.
4
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
Key Words: Ranula, Sublingual gland, Recurrent, Excision
5
ACCEPTED MANUSCRIPT
INTRODUCTION Ranula is a cystic lesion located on the floor or the mouth that arises from
RI PT
trauma or obstruction of the excretory duct of the sublingual gland.1-4 According to the location, ranulas are classified into three groups: the sublingual type,
SC
sublingual-submandibular type, and submandibular type.4,5 The sublingual ranula (simple ranula) is a mucus retention cyst or more commonly a mucus
M AN U
extravasation pseudocyst confined to the floor of the mouth.1 Plunging ranula or cervical ranula (sublingual-submandibular type, submandibular type) appears as a submandibular mass without visible intraoral involvement.1,4
TE D
There were various diagnostic methods of a ranula ranging from clinical observation alone to fine needle aspiration and imaging.3 We have considered
EP
clinical observation and computed tomography (CT) to be a valuable and
AC C
sufficient technique for the assessment of ranula. Although most ranulas are currently treated by surgery, the standard treatment of ranula is still controversial.6 In simple ranula, the lesions are easily observed and are usually treated by incision and drainage, marsupialization, and sclerotherapy at a local hospital. However, in some cases, the simple ranulas recur, necessitating referral to a tertiary medical center.
6
ACCEPTED MANUSCRIPT
Presently, we sought to determine the optimum surgical treatment of simple ranula and also analyzed the clinical characteristics and treatment outcomes of
AC C
EP
TE D
M AN U
SC
RI PT
simple ranula in our hospital.
7
ACCEPTED MANUSCRIPT
MATERIALS and METHODS After obtaining approval from the Institutional Review Board of Chonnam
RI PT
National University Hwasun Hospital, a retrospective review was performed to evaluate patients with a diagnosis of simple ranula at the hospital’s Department
SC
of Otolaryngology-Head and Neck Surgery from November 2007 to August
M AN U
2013. Twenty-four patients with a diagnosis of simple ranula were identified based on their medical records. Patients with plunging ranula were excluded. Clinical data of simple ranula were reviewed including sex, age, symptoms, duration of symptoms, location and size of lesion, surgical procedures,
TE D
complications, recurrence, and follow-up. Eighteen of the 24 patients underwent preoperative computed tomography
EP
(CT) to assess the extent of the simple ranula. All 24 patients had simple ranula
AC C
surgically removed with an intraoral approach under general anesthesia. A descriptive analysis was performed for each of the variables, and correlation determined using the chi-square test. Statistical significance was considered for p < 0.05.
8
ACCEPTED MANUSCRIPT
RESULTS This group of 24 patients included 10 (41.7%) males and 14 (58.3%) females.
RI PT
The age of the patients ranged between 4 and 58 years with a mean of 21.0 ± 16.4 years. All patients presented with an asymptomatic enlarging mass within
SC
the mouth floor. The duration of symptoms ranged from 0.2 - 60 months with a
M AN U
mean of 5.5 ± 11.8 months. Eight ranulas were located on the right side (33.3%) and 16 on the left (66.7%). The size of simple ranula varied between 1 and 3 cm in 10 cases, four cases were < 1 cm, and 10 cases were > 3 cm. Sixteen patients (66.7%) showed no treatment history before visiting our clinic
TE D
(Table 1). The remaining 8 patients had undergone previous treatment by another hospital. However, the simple ranula recurred and the patients were
EP
referred to our clinic. Two patients had undergone Picivanyl injection
AC C
sclerotherapy. Four patients had a history of incision and drainage, one patient had undergone micromarsupialization. Another patient underwent three incision and drainage procedures and three micromarsupializations at a local hospital. Eighteen patients (75%) underwent preoperative CT to assess the extent of the simple ranula (Table 2). All patients with simple ranulas ≤ 1 cm were not diagnosed by preoperative CT scan, while all patients with simple ranulas
9
ACCEPTED MANUSCRIPT
exceeding 1 cm were diagnosed by preoperative CT scan. The size of lesions and diagnosis of lesions by CT scan were statistically significantly different (p =
RI PT
0.007).
All patients except one underwent removal of ranula and sublingual gland.
SC
One patient underwent only ranula excision without removal of sublingual gland,
M AN U
because the size of lesion was very small. All eight patients with recurrent simple ranula after previous treatment by another hospital were treated by excision of the ranula and sublingual gland.
There were no postoperative complications including infection and bleeding.
TE D
One patient with a history of sclerotherapy presented a partial numbness of tongue sensation that resolved within 2 months after surgery. There was no
EP
transient or permanent hypoglossal nerve palsy in this study.
AC C
The mean follow-up was 44.1 ± 17.0 months (range 15 - 82 months). Twelve months after the surgery, recurrence was found in one case (4.2%). The patient had no previous treatment history and had a huge (4.8 x 2.2 cm) sized ranula. According to the operation record, ranula was connected to the deeper portion of sublingual space, and surgeon could not be sure to remove all ranula and sublingual gland. Therefore, the reasons of recurrence were considered
10
ACCEPTED MANUSCRIPT
residual ranula cystic wall and sublingual gland tissue. The patient wanted the
AC C
EP
TE D
M AN U
SC
RI PT
re-operation at another hospital and was referred.
11
ACCEPTED MANUSCRIPT
DISCUSSION Ranula occurs in 1 - 10% of cases and has a prevalence of 0.2 cases per
RI PT
1000 persons.3 Ranulas are generally asymptomatic, but if the size is large, it may affect swallowing, speech, mastication, or breathing.3,7 In this study, all
SC
patients were asymptomatic. The etiology of the ranula is unknown, but has
M AN U
been described in association with the sublingual gland.1,8 It is usually related to trauma to the sublingual gland or the duct and scar formation following this may cause obstruction.3
The diagnosis of ranula is made on clinical and imaging findings.3,9,10 Clinical
TE D
examination provides most of the diagnostic information.1,3 Imaging modalities include ultrasound, CT scan, and magnetic resonance imaging (MRI). CT and
EP
MRI may aid in the preoperative diagnosis and differential diagnosis in some
AC C
cases of plunging ranula.9,10 Some authors suggested that CT and MRI may aid in the preoperative diagnosis but they do not employ either unless the diagnosis is in doubt.1,3 In this study, 18 patients (75%) underwent preoperative CT to assess the extent of the ranula. The size of lesions and diagnosis of lesions by CT scan were statistically significantly different. Therefore, if the size of simple ranula was < 1 cm, the surgeon could refrain from a routine CT scan.
12
ACCEPTED MANUSCRIPT
There are many surgical and non-surgical interventions to treat ranulas.3,11 However, surgery remains the mainstay treatment for simple ranula.3,7,8,9,11 The
sublingual
gland,
incision
and
drainage,
RI PT
wide variety of surgical procedures include ranula excision, excision of marsupialization,
and
SC
micromarsupialization. Incision and drainage should not be performed because
M AN U
of the resulting rapid closure of the wound and recurrence of ranula.11,12 Marsupialization was once considered as the treatment of choice for ranula and is still used.3,7 However, marsupialization is associated with high recurrence rates and extension to plunging ranula.1,2,11,13
TE D
Ranula excision also is associated with high rates of recurrence and is not widely used.4 However, ranula excision may be useful in some cases, such as
EP
superficial and protruding, within a small sized simple ranula.2 In this study, we
AC C
performed only one simple ranula excision that satisfied the aforementioned options. Recurrence did not occur. Since the introduction of micromarsupialization in 1995, the procedure can be easily performed at the outpatient clinic and leads to less discomfort and fewer complications.11,14,15 However, there have been no reported results of efficacy and safety of long-term follow-ups and have not been investigated in studies
13
ACCEPTED MANUSCRIPT
with a large sample size. In this study, there were two patients with recurrence after micromarsupialization before visiting our clinic. In addition, one patient
RI PT
required care at the emergency department after the micromarsupialization because of acute severe swelling of the floor of the mouth. The other patient with
a
recurrent
lesion
despite
multiple
revision
SC
presented
micromarsupializations.
M AN U
While the optimum treatment is still open to debate,6 we believe that ranula removal combined with sublingual gland excision via intraoral approach is the ideal treatment for simple ranula.2,3,4,8 In this study, the recurrence of simple
TE D
ranula after the excision of ranula and sublingual gland was found in only one case (4.2%) among 24 patients. In eight patients with recurrent simple ranula
EP
after previous treatment by another hospital, there was no recurrence after the
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excision of ranula and sublingual gland. Complications associated with procedures for the treatment of ranula include injury to Wharton’s duct, lingual nerve injury, sensory impairment of the tongue, bleeding or hematoma, and wound dehiscence.7,9,16 Excision of the sublingual gland is associated with a major risk of injury to the lingual nerve and Wharton’s duct.9,10 There was no permanent injury to the lingual nerve and Wharton’s duct
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in this study. This study has some limitations due to its small sample size and retrospective
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review. However, our study strongly suggest that intraoral excision of ranula and sublingual gland can be used an ideal treatment for simple ranula, even if
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recurrent simple ranula after previous treatment. Further studies are needed to
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confirm our results.
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CONCLUSIONS Excision of ranula and sublingual gland via the intraoral approach is the ideal
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treatment for simple ranula. Especially, intraoral excision of ranula and sublingual gland provides a 100% success rate in managing recurrent simple
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ranula (n=8) after previous treatment with minimal complications. In addition, if
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the size of simple ranula is <1 cm, CT scan is not necessary.
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REFERENCES 1. Davision MJ, Morton RP, Mclvor NP. Plunging ranula: clinical observations.
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Head Neck. 1998;20(1):63-68.
2. Morita Y, Sato K, Kawana M, Takahasi S, Ikarashi F. Treatment of ranula –
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excision of the sublingual gland versus marsupialization. Auris Nasus Larynx.
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2003;30(3):311-314.
3. Ghani N, Ahmad R, Rahman RA, Yunus MR, Putra SP, Ramli R. A retrospective study of ranula in two centres in Malaysia. J Maxillofac Oral Surg. 2009;8(4):316-319.
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4. Yang Y, Hong K. Surgical results of the intraoral approach for plunging ranula. Acta Otolaryngol. 2014;134(2):201-205.
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5. Woo JS, Hwang SJ, Lee HM. Recurrent plunging ranula treated with OK-
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432. Eur Arch Otorhinolaryngol. 2003;260(4):226-228. 6. Patel MR, Deal AM, Shockley WW. Oral and plunging ranulas: What is the most effective treatment? Laryngoscope. 2009;119(8):1501-1509. 7. Bonet-Coloma C, Minguez-Martinez I, Aloy-Prosper A, Galan-Gil S, Penarrocha-Diago M, Minguez-Sanz JM. Pediatric oral ranula: clinical follow-up study of 57 cases. Med Oral Patol Oral Cir Bucal. 2011;16(2):e158-162.
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8. Huang SF, Liao CT, Chin SC, Chen IH. Transoral approach for plunging ranula – 10 year experience. Laryngoscope. 2010;120(1):53-57.
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9. Sigismund PE, Bozzato A, Schumann M, Koch M, Iro H, Zenk J. Management of ranula: 9 years’ clinical experience in pediatric and adult
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patients. J Oral Maxillofac Surg. 2013;71(3):538-544.
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10. 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):281-287. 11. Woo SH, Chi JH, Kim BH, Kwon SK. Treatment of intraoral ranulas with micromarsupialization: Clinical outcomes and safety (From a Phase II Clinical
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Trial). Head Neck. 2013 Dec 22 [Epub ahead of print]. 12. Crysdale WS, Mendelsohn JD, Conley S. Ranula-mucoceles of the oral
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cavity: experience in 26 children. Laryngoscope. 1988;98(3):296-298.
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13. Haberal I, Gocmen H, Samim E. Surgical management of pediatric ranula. Int J Pediatr Otorhinolaryngol. 2004;68(2):161-163. 14. Morton RP, Bartley JR. Simple sublingual ranulas: pathogenesis and management. J Otolaryngol. 1995;24(4):253-254. 15. Delbem AC, Cunha RF, Vieira AE, Ribeiro LL. Treatment of mucus retention phenomena in children by the micro-marsupialization technique: case
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reports. Pediatr Dent. 2000;22(2):155-8.
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of ranulas. J Oral Maxillofac Surg. 2005;63(1):51-54.
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16. Zhao YF, Jia J, Jia Y. Complications associated with surgical management
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Table 1. Previous treatment history. Number of patients (%)
None
16 (66.7)
Incision and drainage
4 (16.7)
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Micromarsupialization
2 (8.3)
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Picivanyl injection
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Treatment
1 (4.2) 1 (4.2)
Total
24 (100)
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Incision and drainage, micromarsupialization
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Table 2. Preoperative CT scans. Diagnosis by CT scan (%)
< 1 cm
0 / 2 (0)
1 - 3 cm
7 / 7 (100)
> 3 cm
9 / 9 (100)
Total
16 / 18 (88.9)
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Size of Ranula (cm)
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Dear Editor-in-Chief,
Excision of ranula and sublingual gland via the intraoral approach is the ideal
is < 1 cm, CT scan is not necessary.
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Sincerely yours,
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treatment for simple ranula, especially recurrent simple ranula. If simple ranula
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Lee DH