Plunging ranula

An unusual clinical presentation of a plunging ranula-The plunging ranula with extension to the vallecula

Key Clinical Message

A plunging ranula may present initially as an extensive vallecular cyst and correct diagnosis may be reached with the use of ultrasound, fluid aspiration for amylase detection, and MRI imaging.

Abstract

The ranula is a pseudocyst of the sublingual salivary gland and can be divided into two known subtypes. The simple ranula and plunging ranula. While the simple type can be found in the floor of the mouth, the plunging ranula usually pervades the mylohoid muscle and presents as a cervical swelling. The presented case should outline the difficulties in diagnostic and treatment of an uncommon expression of a mucocele above the mylohoid muscle without presenting either a cervical or an intraoral swelling, only extending towards the vallecula. We present a previously unreported clinical manifestation of a ranula of an 18-year old male, which extends posteriorly, remaining confined in the supramylohyoid muscle space. The cystic lesion protrudes in the oropharynx, and clinically appears as an extensive vallecular cyst. On magnetic resonance imaging the initial suspected diagnosis of a vallecular cyst was changed to the final diagnosis of a plunging ranula. The marsupialization of the cyst sac was performed. Outpatient follow-up revealed a persisting ostium, indicating a continuous extravasation of the sublingual gland. The present case report describes an unusual clinical presentation of a plunging ranula, remaining above the mylohyoid muscle and protruding into the oropharynx, misdirecting to the first suspected diagnosis of a vallecular cyst. The case highlights the useful contribution of the MRI imaging for differential diagnoses and the need for criteria to indicate further investigations.

Diagnostic Difficulties of Plunging Ranula: A Review of 18 Cases

OBJECTIVE(S)

Despite advancements in imaging techniques and cytological analysis, plunging ranula remains a challenging surgical, radiologic, and pathologic phenomenon. Of the 18 patients we evaluated at our institution, we highlight three cases that illustrate the high rate of misleading imaging and cytological results when assessing plunging ranula.

METHODS

Imaging results, biopsy findings, operative techniques, and pathological reports were reviewed from patients who had either a preoperative or postoperative diagnosis of ranula and underwent surgery by a single head and neck surgeon at a tertiary care center.

RESULTS

Of the 18 identified patients, computed tomography was correct on preoperative imaging 73% of the time and magnetic resonance imaging was correct on preoperative imaging 71% of the time. Two patients underwent preoperative ultrasound and their ultrasound reports did not accurately diagnose the presence of a ranula. Two patients underwent preoperative fine needle aspiration biopsy due to inconclusive preoperative imaging, in which results suggested either a ranula or epidermal cyst. Both ultimately did not match the final pathology. Three of eighteen patients (17%) underwent an inappropriate initial surgery due to incorrect imaging diagnoses and/or biopsy findings.

CONCLUSION

Despite use of preoperative modalities to distinguish plunging ranula from other cystic floor of mouth lesions, surgeons must be aware that no workup modality is fully precise. The potential for revision surgery must be included in all preoperative discussions for presumed plunging ranula.

LEVEL OF EVIDENCE

4 Laryngoscope, 134:2689-2696, 2024.

Recurrent Plunging Ranula Due to a Sublingual Ectopic Gland: A Rare Clinical Entity

Ranula is a benign cystic lesion caused by the escape and collection of salivary mucus. Classically, it is divided into simple ranulas, a cystic mass in the floor of the mouth, and diving/plunging/cervical ranulas, a submandibular mass without apparent intraoral involvement. Although plunging ranula is a well-documented cause of neck swelling, its association with the presence of ectopic sublingual glands is extremely rare, with less than five cases reported. Other cervical cystic lesions may have the same clinical aspect; therefore, advanced diagnostic techniques like a CT scan or MRI play a critical role in early diagnosis. Different approaches have been used to treat ranulas, including non-invasive, minimally invasive, and surgical techniques. The purpose of this paper is to highlight a case report of a giant plunging ranula due to an anatomical aberration of the right sublingual gland, along with a significant literature review.

A Rare Case of Congenital Plunging Ranulas: Diagnosis With Intraoral and Extraoral Ultrasound and Magnetic Resonance Imaging

Ranulas are cystic lesions located in the floor of the mouth. These are "pseudocysts" and are developed due to an obstruction in the sublingual gland. Congenital variants of plunging ranulas are very rare. Here, we report a case of an eight-year-old male child presenting with congenital swelling with an intraoral component as well as extension to the submandibular gland region. The swelling was painless and gradually growing in size.

Recurrent extensive plunging ranula: A rare case

Plunging ranula (PR) is a cystic mass presenting on the lateral side of the neck with or without a history of the usual presentation of an intraoral lesion. "PR" is recognized as an uncommon lesion that has been found predominantly in the third decade of life mostly in males. However, the exact prevalence of "PR" is not yet known. We report a rare case of an extensive PR that reached the parapharyngeal space in a 17-year-old Saudi female. The diagnosis was made when she presented to the ENT clinic with swellings in the right submandibular and right floor of the mouth. The diagnosis of "PR" with the absence of an oral lesion is very challenging and requires a detailed history, clinical examination, and radiological imaging. Different modalities of treatment have been discussed. However, the excision of ranula and the sublingual gland is the most effective way of management.

Submental epidermoid cysts in children

Epidermoid cysts are lesions, which form as a result of implantation of the epidermis in the layers of the dermis or the mucous membrane. The lesions are rare in adults with 7% occurring in the head and neck area and most often located in the submental region. In children population submental epidermoid cysts are extremely rare. The differential diagnosis of the lesions is necessary as it affects the choice of treatment methods. Among the pathological conditions occurring in that region, salivary retention cyst (ranula), thyroglossal duct cyst, vascular lymphatic malformation (cystic hygroma), median neck cyst, lymphadenopathy, thyroid gland tumor, laryngeal cyst, epidermoid and dermoid cysts, submental abscess, sialolithiasis and salivary gland inflammation should be considered. The authors of the present report demonstrate two cases of submental epidermoid cysts in children. Differential diagnosis in case of suspected submental epidermoid cyst in a child with proposed clinical practice and literature review is provided.

Plunging ranula of the submandibular area

The term "ranula" is used to describe a diffuse swelling in the floor of the mouth caused by either a mucous extravasation or, less commonly, a mucous retention cyst derived from the major sublingual or submandibular salivary glands. The most common presentation of ranula is a painless, slow-growing, soft, and movable mass located in the floor of the mouth. Ranula may be simple or plunging. Simple ranula often present as masses in the floor of the mouth, limited to the mucous membranes. Diving ranulas extend through the facial plans, usually posterior to the mylohyoid muscle into the neck, and present as cervical masses. Thyroglossal duct cyst, branchial cleft cyst, cystic hygroma, submandibular sialadenitis, intramuscular hemangioma, cystic or neoplastic thyroid disease might be included in differential diagnosis. A variety of surgical procedures have been quoted in the literature ranging from marsupialization, excision of the ranula, sclerotherapy, and excision of the sublingual gland. The recurrence rate varies according to the procedure performed.