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Treatment of Ranula*
TREATMENT OF RANULA By M ENIFEE R . H O W A R D , D.D .S., D enver, Colorado
A N U L A rarely com es to the a t tention o f the d en tal oral surgeon, b u t w hen it does occur, it m ay be a stubborn condition an d exact the m ost skilled services o f the operator.
R
E T IO L O G Y I t arises fro m an obstruction or ir ri tation a t the orifice or w ith in the duct caused by the fo rm a tio n o f salivary calculus, entrance o f fo re ig n bodies or trau m a. T h e ducts or orifices m ost com m only involved are those leading fro m th e subm ental, subm axillary or subm ucous glands. Its sym ptom s are a chronic, slow or rapidly g ro w in g sw ellin g , usually in the a n te rio r p art o f the floor o f the m outh. I t is a bluish gray o r even a reddish gray. I t w ill n o t pit or d en t on pressure and is usually tense.
D IF F E R E N T IA L D IAGNOSIS A lipom a m ig h t be m istaken fo r ran u la , but, on palpation, it can readily be d ifferen tiated , as the lipom a is so ft an d readily collapsible. T h e tre a tm e n t is alw ays surgical and m ay be done by various m eans, depend in g on the history an d developm ent. T h e tre a tm e n t o f the sm aller ra n u la or those o f recent origin m ay be as f o l low s: A sim ple incision is m ade into the
*Read before the American Society o f Oral Surgeons and Exodontists, Philadelphia, Pa., Aug. 20, 1926.
Jour. A. P . A., November, 1927
ra n u la an d the contents are evacuated. P h en o l, f u ll stren g th , is applied to the cut edges o f the incision, w hich ten d to re ta rd im m ediate closure o f the w ound. T h e p atien t is observed daily fo r some tim e, an d the opening thus established, is m ain tain ed . O n account o f the likeli hood o f th e cu t edges h ealin g an d clos ing, this m ethod is successful in only a sm all percentage o f cases. A m ore sat isfacto ry an d practical m ethod is as fo llo w s: A V or oval shaped incision is m ade in the superior portion o f the ra n u la an d th e flap tu rn ed u n d er and sutured to the rem a in in g cyst w all so as to m ake a sm ooth su rface. T h is m ethod w ill p rev en t the closing o f the w ounds an d is successful in a la rg e p er centage o f cases. T h e anesthetic used m ay be either procain or gas oxygen, or oth er g en eral anesthetics, depending on the ju d g m e n t o f the operator. B la ir recom m ends, in m any cases, the com plete excision o f the ran u la , but on acco u n t o f such an operation being a serious one, this rad ical operation should be approached cautiously and only a f te r o th er m ore conservative pro cedures have failed . B rophy’s trea tm e n t, by m eans o f the silver rin g m ethod, is as fo llo w s: A silver tube w ith a gage o f 3 m m ., curved so as to fo rm a circle o n e -h a lf inch in d iam eter, is used. T h e rin g is p erfo ra ted w ith m any holes. T w o punctures are m ade in the cyst w all, 2094
H award— Treatm ent of Ranula an d the rin g is placed th ro u g h one opening and then the oth er an d the ends o f the rin g are telescoped. T h is is allow ed to rem ain u n til the' fre sh ened tissues heal aro u n d the rin g , thereby establishing a p erm a n en t d ra in age. T h e tube is ro tated daily to p re vent the fo rm a tio n o f g ran u la tio n . H eavy w axed braided silk, or even silver w ire, instead o f a silver tube m ay be used. REPORT OF CASE
In a case o f ranula, resulting from trauma to Wharton’s duct, the patient, a man, aged 50, and weighing. 150 pounds, while at a railroad roundhouse accidentally fell into a pit, landing on and injuring his left jaw. A swelling developed on the left jaw and in the mouth, lasting several days. The patient’s description o f the case was as follow s: For fourteen years after this accident, at intervals o f one or two years, there was a hard swelling of tissue under the tongue, occurring after a cessation of the saliva on the left side. For the first eight years, this condition occurred every two years, and for the next six years it occurred once annually. The cystic sac developed during such disturbances, and after a few days, would break spontaneously, after which the conditions about the face and jaws would return to normal. The last attack, just pre ceding the time the patient came in, had lasted
2095
about four months, and had developed into Ludwig’s angina. The patient also reported that, during the past three years, he had a feeling that an enlargement under the left jaw was in process, in the submaxillary re gion. At the clinical examination, a diagnosis was made o f pus in the submaxilliary glands and other glands o f the neck. Subsequent operation confirmed this diagnosis. Drainage was maintained for about six weeks, during which the pus condition subsided, and the swelling also subsided and tenderness dis appeared. About three months after the original incision, two large salivary calculi, each the size o f a thumb, were removed from the left submaxillary glands, together with the glands. T w o years have now elapsed since the operation, with no report o f further disturbance or swelling under the tongue. The ranula within the mouth disappeared after the above described operation. CONCLUSION I t should alw ays be rem em bered th a t, in m o it cases, the w alls w ill reunite and the ra n u la recu r unless a p erm an en t opening is m ain tain ed . F o r this rea son, an operation f o r ra n u la should n o t be considered too lig h tly on account o f the d an g e r o f recu rren ce. W h e n an operation has been decided on, it should be done w ith such care, skill an d defini tion th a t th e chances o f recu rren ce w ill be largely elim inated.
A N U L A rarely com es to the a t tention o f the d en tal oral surgeon, b u t w hen it does occur, it m ay be a stubborn condition an d exact the m ost skilled services o f the operator.
R
E T IO L O G Y I t arises fro m an obstruction or ir ri tation a t the orifice or w ith in the duct caused by the fo rm a tio n o f salivary calculus, entrance o f fo re ig n bodies or trau m a. T h e ducts or orifices m ost com m only involved are those leading fro m th e subm ental, subm axillary or subm ucous glands. Its sym ptom s are a chronic, slow or rapidly g ro w in g sw ellin g , usually in the a n te rio r p art o f the floor o f the m outh. I t is a bluish gray o r even a reddish gray. I t w ill n o t pit or d en t on pressure and is usually tense.
D IF F E R E N T IA L D IAGNOSIS A lipom a m ig h t be m istaken fo r ran u la , but, on palpation, it can readily be d ifferen tiated , as the lipom a is so ft an d readily collapsible. T h e tre a tm e n t is alw ays surgical and m ay be done by various m eans, depend in g on the history an d developm ent. T h e tre a tm e n t o f the sm aller ra n u la or those o f recent origin m ay be as f o l low s: A sim ple incision is m ade into the
*Read before the American Society o f Oral Surgeons and Exodontists, Philadelphia, Pa., Aug. 20, 1926.
Jour. A. P . A., November, 1927
ra n u la an d the contents are evacuated. P h en o l, f u ll stren g th , is applied to the cut edges o f the incision, w hich ten d to re ta rd im m ediate closure o f the w ound. T h e p atien t is observed daily fo r some tim e, an d the opening thus established, is m ain tain ed . O n account o f the likeli hood o f th e cu t edges h ealin g an d clos ing, this m ethod is successful in only a sm all percentage o f cases. A m ore sat isfacto ry an d practical m ethod is as fo llo w s: A V or oval shaped incision is m ade in the superior portion o f the ra n u la an d th e flap tu rn ed u n d er and sutured to the rem a in in g cyst w all so as to m ake a sm ooth su rface. T h is m ethod w ill p rev en t the closing o f the w ounds an d is successful in a la rg e p er centage o f cases. T h e anesthetic used m ay be either procain or gas oxygen, or oth er g en eral anesthetics, depending on the ju d g m e n t o f the operator. B la ir recom m ends, in m any cases, the com plete excision o f the ran u la , but on acco u n t o f such an operation being a serious one, this rad ical operation should be approached cautiously and only a f te r o th er m ore conservative pro cedures have failed . B rophy’s trea tm e n t, by m eans o f the silver rin g m ethod, is as fo llo w s: A silver tube w ith a gage o f 3 m m ., curved so as to fo rm a circle o n e -h a lf inch in d iam eter, is used. T h e rin g is p erfo ra ted w ith m any holes. T w o punctures are m ade in the cyst w all, 2094
H award— Treatm ent of Ranula an d the rin g is placed th ro u g h one opening and then the oth er an d the ends o f the rin g are telescoped. T h is is allow ed to rem ain u n til the' fre sh ened tissues heal aro u n d the rin g , thereby establishing a p erm a n en t d ra in age. T h e tube is ro tated daily to p re vent the fo rm a tio n o f g ran u la tio n . H eavy w axed braided silk, or even silver w ire, instead o f a silver tube m ay be used. REPORT OF CASE
In a case o f ranula, resulting from trauma to Wharton’s duct, the patient, a man, aged 50, and weighing. 150 pounds, while at a railroad roundhouse accidentally fell into a pit, landing on and injuring his left jaw. A swelling developed on the left jaw and in the mouth, lasting several days. The patient’s description o f the case was as follow s: For fourteen years after this accident, at intervals o f one or two years, there was a hard swelling of tissue under the tongue, occurring after a cessation of the saliva on the left side. For the first eight years, this condition occurred every two years, and for the next six years it occurred once annually. The cystic sac developed during such disturbances, and after a few days, would break spontaneously, after which the conditions about the face and jaws would return to normal. The last attack, just pre ceding the time the patient came in, had lasted
2095
about four months, and had developed into Ludwig’s angina. The patient also reported that, during the past three years, he had a feeling that an enlargement under the left jaw was in process, in the submaxillary re gion. At the clinical examination, a diagnosis was made o f pus in the submaxilliary glands and other glands o f the neck. Subsequent operation confirmed this diagnosis. Drainage was maintained for about six weeks, during which the pus condition subsided, and the swelling also subsided and tenderness dis appeared. About three months after the original incision, two large salivary calculi, each the size o f a thumb, were removed from the left submaxillary glands, together with the glands. T w o years have now elapsed since the operation, with no report o f further disturbance or swelling under the tongue. The ranula within the mouth disappeared after the above described operation. CONCLUSION I t should alw ays be rem em bered th a t, in m o it cases, the w alls w ill reunite and the ra n u la recu r unless a p erm an en t opening is m ain tain ed . F o r this rea son, an operation f o r ra n u la should n o t be considered too lig h tly on account o f the d an g e r o f recu rren ce. W h e n an operation has been decided on, it should be done w ith such care, skill an d defini tion th a t th e chances o f recu rren ce w ill be largely elim inated.