Congenital atresia of the orifice of the submandibular duct: a report of 2 cases and review

[Diagnosis and treatment of congenital submandibular duct dilatation]

OBJECTIVE

To study the clinical features and treatments of congenital submandibular duct dilatation.

METHODS

Seven children with congenital submandibular duct dilatation from January 2008 to March 2018 were included in this study, whose average age was 5 months and 22 days. The clinical manifestations are unilateral swelling of the mouth floor. All seven children underwent sublingual gland resection, submandibular gland dilatation catheter resection, and catheter reroute under general anesthesia. Intraoperatively, the orifice of the submandibular gland was constricted and part of the catheter was dilated.

RESULTS

All seven patients had good healing without swelling or cyst formation.

CONCLUSIONS

Congenital submandibular duct dilatation occurs at a young age. Early diagnosis and treatment can help prevent further expansion of the catheter and avoid gland atrophy, feeding difficulty, and breathing obstruction. Simultaneous excision of the sublingual gland can avoid the formation of postoperative sublingual cyst.

Unusual Conditions Impairing Saliva Secretion: Developmental Anomalies of Salivary Glands

Salivary glands (SG) arise from ectodermal tissue between 6 and 12th weeks of intrauterine life through finely regulated epithelial-mesenchymal interactions. For this reason, different types of structural congenital anomalies, ranging from asymptomatic anatomical variants to alterations associated with syndromic conditions, have been described. Notable glandular parenchyma anomalies are the SG aplasia and the ectopic SG tissue. Major SG aplasia is a developmental anomaly, leading to variable degrees of xerostomia, and oral dryness. Ectopic SG tissue can occur as accessory gland tissue, salivary tissue associated with branchial cleft anomalies, or true heterotopic SG tissue. Among salivary ducts anomalies, congenital atresia is a rare developmental anomaly due to duct canalization failure in oral cavity, lead to salivary retention posterior to the imperforate orifice. Accessory ducts originate from the invagination of the developing duct in two places or from the premature ventral branching of the main duct. Heterotopic ducts may arise from glandular bud positioned in an anomalous site lateral to the stomodeum or from the failure of the intraoral groove development, hindering their proximal canalization. These anomalies require multidisciplinary approach to diagnosis and treatment. While ectopic or accessory SG tissue/ducts often do not require any treatment, patients with SG aplasia could benefit from strategies for restoring SG function. This article attempts to review the literature on SG parenchyma and ducts anomalies in head and neck region providing clinicians with a comprehensive range of clinical phenotypes and possible future applications of bioengineered therapies for next-generation of regenerative medicine.

Congenital Ranula: A Case Report and Literature Review

Ranula consists of a pathological process induced by ductal disruption of the minor salivary glands followed by extravasation of mucous material surrounding adjacent structures. A swelling causing breathing and feeding problems associated with tongue displacement is frequently observed. It is a disease that generally involves the younger age group. In newborns congenital ranula may occur, an uncommon variance that differs from common ranula by not relate to post-traumatic reactions. There are reports that indicate a salivary gland duct atresia as the main cause of this pathology. The aim of this study is to analyze the clinicopathological characteristics of congenital ranula by reporting a new case report of this salivary cyst and reviewing the case reports previously published in the English literature.

Serious neonatal airway obstruction with massive congenital sublingual ranula and contralateral occurrence

Background

Congenital ranulas seldom occur, with bilateral presentation and prenatal diagnosis reported very rarely. We believe this is the first reported case of a neonate with a antenally diagnosed massive congenital ranula, who went on to develop a non-contiguous contralateral ranula, both contributing to obstruction in a complex paediatric airway.

Case report

A female neonate was born to a non-primagravid mother via a planned elective caesarean section due to a lower facial defect and oral cyst. Antenatal aspiration of the pseudocyst was performed under ultrasound guidance with limited success. In the immediate post-natal period a poor airway was observed and the cyst was subsequently marsupialised. With the development of macroglossia secondary to oedema and tongue base collapse the airway was secured through surgical tracheostomy. A subsequent ultrasound scan revealed the presence of a second solitary cystic mass on the contralateral side. After careful excision of the contralateral pseudocyst, tongue function improved, with the resolution of a safe airway which permitted successful decannulation. A planned definitive procedure antenatally did not result in the anticipated improvement in function. However the subsequent development of a second non-contiguous pseudocyst and further surgical management resulted in a safe airway, improved masticator function and the ability to thrive.

Conclusions

The prenatal diagnosis of congenital ranulas have been seldom reported, with no reported cases of contralateral occurrence and airway obstruction from an intraoral ranula. This rare case highlights the need for a well considered contingency plan when surgery is required for a neonatal airway at risk.

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A well considered plan is required when a neonatal surgical airway is required.

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Intra-oral ranulas can be initially managed with marsupialisation or cyst excision.

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Sublingual gland excision is more reliable but associated with higher risk.

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Sublingual gland excision should be reserved for recalcitrant cysts.

Floor of mouth masses in children: proposal of a new algorithm

OBJECTIVE

Many surgical techniques have been described to manage floor of mouth masses, but few studies have described the approach to these masses in children. This case series summarizes a single institution's experience with pediatric floor of mouth masses.

METHODS

We performed a retrospective chart review of all children who presented at our tertiary care facility with FOM masses between 2007 and 2012. Charts were reviewed for clinical presentation, preoperative, intraoperative and postoperative management.

RESULTS

Thirteen cases were retrieved: 6 dermoid cysts, 4 ranulas, 1 lymphatic malformation, 1 imperforate submandibular duct, and 1 enlarged salivary gland. In 10 of 13 patients, clinical diagnosis was consistent with postoperative diagnosis. Imaging was consistent with postoperative diagnosis in 8 of 9 cases. Ten of 13 masses were managed transorally; 7 were excised, 2 were marsupialized and 1 was managed with submandibular duct dilation. Three masses with a larger submental component, 2 dermoids and 1 ranula, were removed transcervically. Most patients undergoing transoral excision underwent nasotracheal intubation; patients who underwent marsupialization underwent orotracheal intubation. There were no recurrences, complications or postoperative infections. An additional surgical procedure was necessary in one patient.

CONCLUSION

Our cohort displays a common distribution of lesion types when compared to the literature. Low recurrence and infection rates are observed when oral masses are removed transorally, and masses with a larger cervical component are removed transcervically. More complex masses may warrant additional surgical procedures.

Modern management and pathophysiology of ranula: literature review

BACKGROUND

There is a lack of consensus about the appropriate treatment of ranula. The objective of the present investigation was to produce a scientific basis for treatment.

METHODS

A review of the relevant literature is interpreted in the light of improved knowledge about the local anatomy and the pathophysiology of the salivary glands.

RESULTS

The oral and plunging ranulas are cystic extravasation mucoceles that arise from the sublingual gland and usually from a torn duct of Rivinus. The sublingual gland is a spontaneous secretor and the salivary flow is resistant to obstruction, which is caused by fibrosis induced by the extravasation. The submandibular gland is not a spontaneous secretor, is less resistant, and does not give rise to ranulas.

CONCLUSIONS

Effective treatment is removal of the involved unit of the sublingual gland or inducing sufficient fibrosis to seal the leak through which the mucus extravasates.

Sialodochostomy as treatment for imperforate submandibular duct: a systematic literature review and report of two cases

OBJECTIVE

To better understand the diagnosis, treatments, and outcomes of congenitally imperforate salivary ducts.

METHODS

A systematic literature review was performed using the following terms: imperforate submandibular duct, imperforate Wharton's duct, congenital atresia submandibular duct, congenital atresia sublingual duct, and congenital ranula. Only papers focusing on congenital floor of mouth cysts arising from imperforate salivary ducts were included. Two additional patients from our own experience are also discussed.

RESULTS

Seventeen papers published since 1950 met inclusion criteria. A total of 26 patients underwent therapy ranging from mere observation to complete excision of the cyst with the sublingual gland. Both of our 2 additional patients both underwent simple sialodochostomy (excision of the imperforate sublingual caruncle) with cyst decompression. For all 28 patients, there have been no reported recurrences, with mean follow-up of 24.8 months and median follow-up of 14.8 months.

CONCLUSIONS

Congenital floor of mouth cysts arising from imperforate salivary ducts are rare, but they may mimic the appearance of a ranula. Unlike ranulas, these cysts may be safely and effectively cured by simple sialodochostomy. To date, 26 other cases have been described in the literature, and nearly all have been successfully treated with simple incision or marsupialization without recurrence. Care should be taken to exclude ranula as a diagnosis, as incomplete excision may likely result in recurrence.

Videosialoendoscopic assessment of bilateral atresia of the Wharton's duct orifice in an infant

Atresia of the submandibular ducts (particularly the duct orifice) is a rare occurrence that is mainly observed in newborns or infants; moreover, its differential diagnosis with other anomalies of the oral floor is sometimes difficult. Given the lack of data concerning the differences between atresia of the orifice of Wharton's duct and other anomalies of the submandibular duct system, we describe here the findings of videosialoendoscopic assessment of the salivary duct system in an infant who underwent traditional surgery for bilateral atresia of the orifice of Wharton's duct. During sialoendoscopy, a trifurcation of the main duct, a normal variant of the more common bifurcation of the secondary branches of the salivary duct system, was observed bilaterally. No other ductal anomalies were encountered. Complete resolution of the symptoms and complete patency of both ducts at 19-month follow-up evaluation were observed. In conclusion, although spontaneous resolution of the disease during feeding is possible, minimal incision of the orifice of the imperforated submandibular duct together with diagnostic videosialoendoscopy of the main salivary duct system may be considered as part of the modern approach to salivary obstructive disorders in pediatric age as is currently the case for sialolithiasis and recurrent juvenile parotitis.

Congenital imperforate submandibular duct in a newborn

Varried conditions such as ranula, epidermal/dermal inclusion cyst, lymphatic cyst, thyroglossal cyst, sialolithiasis, branchial cleft cyst are known to produce swelling in the floor of mouth. Rarely imperforate or duplication anomaly of submandiblar duct may produce cystic lesion in the floor of mouth. We present a case of congenital imperforate submandibular duct with cyst formation in a newborn. We also review the literature regarding management.

Bilateral atresia of the submandibular duct orifices

Atresia of the submandibular duct orifice is a rare developmental anomaly. Early identification and treatment of atresia of the submandibular duct orifice prevent feeding and breathing difficulties, dilatation of the submandibular duct, submandibular gland infection, or pressure atrophy. Imperforate submandibular duct should be distinguished from duplication abnormalities of the duct and other cystic lesions in the floor of the mouth. To date, magnetic resonance imaging findings of the atresia of the submandibular duct orifice have not been reported. The aim of this study was to describe clinical and radiologic evaluation of an infant with atresia of the bilateral submandibular duct orifices.

Congenital Malformations of the Oral Cavity

Congenital malformations of the oral cavity may involve the lips, jaws, hard palate, floor of mouth, and anterior two thirds of the tongue. These malformations may be the product of errors in embryogenesis or the result of intrauterine events disturbing embryonic and fetal growth. This article begins with a review of the pertinent embryologic development of these structures. After reviewing the normal embryology, specific malformations are described. Recommended management follows the brief description of each malformation. An attempt is made to point out where these malformations deviate from normal development. Finally, management recommendations are based on traditional methods and recent advances described in the literature.

Symmetry of the submandibular glands in humans—a postmortem study assessing the linear morphometric parameters

BACKGROUND

The analysis of morphometric right-left symmetry of the salivary glands is important for assessing unilateral changes discovered in these organs during diagnostic imaging.

STUDY DESIGN

A study was carried out on 18 adult human autopsy neck and maxillofacial specimens from both sexes (14 males, 4 females), with age range of 17 to 73 years (mean age 49.9 years). The submandibular duct was injected with contrast medium and images were made in two projection planes.

RESULTS

Morphometry performed using the obtained radiographs included: (a) caliber (mean proximal, middle, and distal = 1.73 mm, 1.82 mm, and 1.77 mm), (b) length (mean = 37.2 mm); (c) genu of the submandibular duct (mean = 114 degrees ); and (d) longitudinal and transverse diameters of the gland (mean = 44.1 mm and 25.9 mm). Comparison of these morphometric parameters between the right and the left glands revealed no statistically significant differences.

CONCLUSION

There is a high level of right-left symmetry in linear morphometric parameters of the submandibular gland.

Cysts and tumors of the oral cavity, oropharynx, and nasopharynx in children

A wide variety of developmental and neoplastic lesions arise in the oral cavity, oropharynx, and nasopharynx in children. The clinical manifestations and cross-sectional imaging findings provide complementary information, which is used to establish a probable or definitive diagnosis. This article describes imaging techniques and findings for developmental cystic masses and solid tumors in the pediatric population.