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British Journal of Oral and Maxillofacial Surgery 53 (2015) 138–141

Minimally invasive treatment of oral ranula with a mucosal tunnel T. Jia a , L. Xing a , F. Zhu b , X. Jin b , L. Liu a , J. Tao a , Y. Chen a , Z. Gao a , H. Zhang a,∗ a b

Oral and Maxillofacial Surgery Department, The Chinese PLA General Hospital, 28 Fuxing Road, Beijing 100853, PR China Bioengineering Center, Wayne State University, 818 W. Hancock, Detroit, MI 48201, USA

Accepted 24 October 2014 Available online 20 November 2014

Abstract We have developed a new method for minimally-invasive treatment of uncomplicated oral ranulas using a mucosal tunnel, and we report the clinical outcome. We constructed a mucosal tunnel for each of 35 patients who presented with an oral ranula, by making 2 parallel incisions across the top of the protruding ranula 2–3 mm apart, and dissected the soft tissue along the incisions to its wall. The fluid was removed and the cavity irrigated with normal saline. The wall of the ranula was not treated. The first mucosal tunnel was made by suturing the base of the mucosal strip to the deepest part of the wall of the ranula. The mucosal base of the tunnel and the deepest part of the base of the ranula were fixed with absorbable sutures. The two external edges of the incisions were sutured together to form the second mucosal tunnel, and apposing sutures were inserted between the two parallel incisions to form two natural mucosal tunnels. The duration of follow-up ranged from 1 to 5 years. One patient was lost to follow-up and 34 patients were cured. Outcomes were satisfactory without relapse during the follow-up period and the patients were satisfied with the outcome. The mucosal tunnel is a safe, effective, simple, and minimally-invasive treatment for oral ranula. © 2014 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Keywords: Ranula; Mucosal tunnel; Minimally invasive treatment

Introduction Ranulas are extravasation mucocoeles that arise from the sublingual gland,1,2 and they can be classified as plunging and intraoral. Most are currently treated by excision together with removal of the sublingual gland.1,2 Many techniques have been described and it is important to choose a safe, effective, easy, and minimally-invasive approach.1,2 Micromarsupialisation is effective for intraoral ranulas, particularly in children.2–4



Corresponding author. Tel.: +86 13901104968; fax: +86 1066938116. E-mail address: [email protected] (H. Zhang).

Since 2007, we have used a minimally-invasive technique with a mucosal tunnel to treat simple intraoral ranulas, and outcomes have been satisfactory.

Patients and methods Thirty-five patients with oral ranulas were treated in our department between January 2007 and January 2012. There were 23 male, and 12 female, patients, age range 4–58 years. The size of the ranulas ranged from 5.5 cm × 4.4 cm to 1.5 × 1.5 cm. In all patients they presented as translucent or light purple cystic masses that protruded from the mucosal surface of the floor of the mouth, and the ranula was

http://dx.doi.org/10.1016/j.bjoms.2014.10.015 0266-4356/© 2014 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

T. Jia et al. / British Journal of Oral and Maxillofacial Surgery 53 (2015) 138–141

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covered with a thin wall and mucosa. A viscous liquid similar to egg-white was aspirated. Operative technique General anesthaesia was used for 2 children and local anaesthesia for the remainder of the patients, all of whom were over 10 years old. The tongue was pulled to one side to expose the whole ranula. Two parallel incisions were made that crossed the apex of the protruding ranula, with about 2–3 mm between them. Adrenaline was injected submucosally below the line of the bridge to reduce bleeding, and then soft tissue was dissected from the incisions to the wall of the ranula. After the fluid had been removed, the cavity was irrigated with normal saline. The wall was not treated. The mucosal base of the tunnel and the deepest part of the ranula were fixed with absorbable sutures, and apposition sutures were placed between the two parallel incisions to form two natural mucosal tunnels. A piece of squamous mucosa on the floor of the mouth 2–3 mm wide was embedded and sutured to the bottom of the ranula to form two tunnels bilaterally. Because the squamous mucosa remained vital, the openings of the tunnels failed to close, and the secreted fluid flowed out through them. In this way, two drainage ports were established (Figs. 1–6). The operative time ranged from 10 to 30 minutes, and intraoperative blood loss ranged from 5 to 10 ml. Sutures were removed about 7 days postoperatively, or left in place. Outcome The ranulas disappeared completely, the mucosa on the floor of the mouth looked normal, and the tongue moved freely. Cure was defined as no recurrence at the 2-year follow-up. Improvement was defined as a considerably reduced ranula that had not completely disappeared. Treatment was deemed unsuccessful if the ranula recurrred. Since 2007, we have tried minimally-invasive surgery using a mucosal tunnel to treat simple intraoral ranulas, and compared the results with those of other techniques. During the period 1992–2007, we used the tunnel for simple intraoral ranulas (n = 119), excised the ranula (n = 5), marsupialised the ranula (n = 13), and excised the sublingual gland and ranula (n = 101).

Fig. 1. The ranula in the left floor of mouth (published with the patient’s permission).

follow-up. Thirty-four cases were cured with no recurrence, and all patients were satisfied with the outcome. The recurrence rate after excision of the sublingual gland and ranula was 2%, after marsupialisation 39%, and after excision of the ranula 80%.

Discussion Ranulas are relatively common cysts of the salivary gland that appear during oral and maxillofacial development. Most are caused by penetration of mucus into the tissues after rupture of the gland or the duct, and they lack an epithelial lining.1,2 In a few cases, they are caused by the retention of secreted fluid in the proximal segment after blockage of the duct of a sublingual gland in the distal segment. Because ranulas are retention cysts, their walls are fibrous. This type of ranula is

Results Because of the squamous mucosa embedded under the bottom of the sublingual gland, the mucosal tunnels did not heal postoperatively, and the natural channels allowed sufficient drainage of cystic fluid for the ranula to disappear. The colour of the mucosa and the secretory function of the sublingual gland were both normal. The duration of followup ranged from 1 to 5 years, and one patient was lost to

Fig. 2. Two parallel incisions were made about 2 mm apart, and the soft tissue dissected along the incisions on the wall of the ranula (published with the patient’s permission).

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T. Jia et al. / British Journal of Oral and Maxillofacial Surgery 53 (2015) 138–141

Fig. 5. Diagram showing the mucosal tunnel made by suturing the base of the mucosal strip to the deepest part of the wall of the ranula.

divided into the simple, extraoral, and dumbbell. The simple type is located within the mouth under the tongue. The extraoral type, also known as “plunging”,5,6 is located in the submandibular area outside the mouth. The dumbbell type is a rare hybrid of the other two. A detailed medical history, careful examination, and aspiration and ultrasonic examination of the ranula allows definitive diagnosis. Ranulas in the submandibular area, if extraoral or dumbbell, should be pressed with a finger. The

volume increases when it is at the bottom of the mouth or when the patient swallows or puts the tongue out. Aspiration of the ranula can remove viscous liquid, which is similar in appearance to egg-white and contains amylase. Currently, ranula can be managed either conservatively or surgically.7–9 One option for conservative treatment is injection of drugs into the cavity of the ranula after complete removal of the fluid. These drugs include 2% iodine; benadryl, lidocaine, and maalox (BLM); BLM + dexamethasone; promethazine hydrochloride solution; anhydrous ethanol; hypertonic saline; 5% cod liver oil; tetracycline hydrochloride; and Picibanil® (OK-432).10 The goal is to destroy the acinar cells within the sublingual gland with subsequent loss of the secretory function of the gland, so preventing recurrences. The procedure is simple, costs are low, and the risks are small. However, the drugs can have adverse effects, the ranulas recur easily, and long-term follow-up is needed. Certain drugs, such as anhydrous ethanol, are not suitable for children, and surgical treatment may be required later. Another method is to treat the ranula wall using laser,11 freezing, electrocautery, and microwave thermal

Fig. 4. Two drainage ports were established (published with the patient’s permission).

Fig. 6. Diagram showing the 2 external edges of the incisions sutured together to form the mucosal bridge.

Fig. 3. The mucosal tunnel was made by suturing the base of the mucosal strip to the deepest part of the wall of the ranula. The 2 external edges of the incisions were sutured together to form the mucosal bridge. A piece of squamous mucosa 2 mm wide was embedded in the floor of the mouth (published with the patient’s permission).

T. Jia et al. / British Journal of Oral and Maxillofacial Surgery 53 (2015) 138–141

coagulation.8,11 Its advantages include a small laser window, less bleeding, and no need for sutures. However, patients should be selected carefully and using strict criteria. Additionally, postoperative ulcers or infections may develop. Channels may also be established by piercing, threading, and ostomy, which are less traumatic and can easily be accepted by patients. However, a lengthy course of treatment and good cooperation are required, and the rate of recurrence is relatively high. Resection is the most common treatment. Traditionally the ranula is removed together with the sublingual gland, and this is the only strategy that can cure the disease.8,11 However, the small space on the floor of the mouth increases difficulties that may arise during the operation. The sublingual gland and its duct have important peripheral vessels and nerves, including the sublingual artery and vein and the lingual nerve, and injury to these structures may cause uncontrollable bleeding, reduced blood supply to the tongue, numbness of the tongue, and infections. In addition, accidental ligation of the submandibular gland may result in various other complications.9 Even though surgical techniques have improved, the risk of injury is still substantial and bleeding may still be appreciable. A normal sublingual gland has to be removed, and unilateral removal of the sublingual gland can also leave a mucosal scar on the floor of the mouth, which may be lower on the affected side than on the healthy side and affect the patient’s appearance. Other surgical treatments include marsupialisation, modified marsupialisation,3,12 and modified packing. These modified procedures, in addition to being minimally invasive and less painful, do not require special equipment. However, the patient has the sensation of a foreign body, and careful selection is needed. Regardless of the treatment that is used to treat ranulas, the best approach is to preserve the sublingual gland, which ensures that physiological functions are maintained. It is therefore important to find an effective, easy, and minimally-invasive procedure that would allow a short course of treatment, reduce postoperative complications, and prevent recurrences. We designed a 2–3-mm wide piece of mucosa and produced tunnels covered by viable squamous mucosa for drainage. The mucosal tunnel did not heal, and a natural pathway was established to drain the ranula fluid completely. This is equivalent to producing two large ducts that lead to the floor of the mouth. Maintenance of the tunnel permits the formation of a new permanent epithelialised tract along its path. Recurrence of the ranula was prevented and successful treatment achieved. Our method is also suitable for less cooperative children and elderly patients who cannot tolerate major operations. The operating time is short, there is little operative blood loss, and the function of the sublingual gland is retained. After the fluid contents of the ranula have been evacuated, the deepest base of the wall is raised automatically and the volume of the cavity is gradually reduced.

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The duration of follow-up ranged from 1 to 5 years. There were varying degrees of contraction in the opening of the mucosal tunnel, which was not closed and formed a mucosal fistula 1–2 years later. This approach provides a safe, effective, simple, minimally-invasive method, and is a new option for the treatment of ranulas.

Conflict of interest We have no conflict of interest.

Ethics statement/confirmation of patients’ permission The local hospital ethics committee approved the protocol. Figs. 1–4 are published with the patient’s permission (Figs. 5 and 6 ).

Acknowledgements This work was supported by a grant from the National Natural Science Foundation of China (No.: 31271004). We thank Dr. Wei Wang and Ms. Anne Clayton for helpful discussions and assistance with writing.

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Minimally invasive treatment of oral ranula with a mucosal tunnel.

We have developed a new method for minimally-invasive treatment of uncomplicated oral ranulas using a mucosal tunnel, and we report the clinical outco...
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