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 Table of Contents  
ORIGINAL RESEARCH REPORT
Year : 2021  |  Volume : 18  |  Issue : 2  |  Page : 109-112

Ranula: A retrospective clinicosurgical analysis of 29 cases from a tertiary health institution, Northwest, Nigeria


1 Department of Otorhinolaryngology, Usmanu Danfodiyo University Teaching Hospital, Sokoto, Nigeria
2 Department of Dental and Maxillofacial Surgery, Usmanu Danfodiyo University Teaching Hospital, Sokoto, Nigeria

Date of Submission24-Jun-2020
Date of Acceptance24-Sep-2020
Date of Web Publication24-Apr-2021

Correspondence Address:
Dr. Mohammed Abdullahi
Department of Otorhinolaryngology, Usmanu Danfodiyo University Teaching Hospital, Sokoto
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcls.jcls_55_20

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  Abstract 


Background: Ranula may grow into a considerable size as to cause obstructive symptoms, especially in infants when neglected. The aim is to describe the clinical presentation, treatment, and outcome of ranulas. Methods: This is a retrospective study of patients with ranulas that presented during the periods of January 2000 to December 2019 in the Department of Otorhinolaryngology, Dental and Maxillofacial Surgery, Usmanu Danfodiyo University Teaching Hospital, Sokoto, Northwest, Nigeria. Results: A total of 29 patients were seen during the review period: twelve (41.4%) males and 17 (58.6%) females. Age ranged from 3 days to 48 years (median 3 years). Most of the patients 19 (65.5%) were below the age of 10 years. Twenty-one (72.4%) patients had simple oral ranulas: 8 (38.1.6%) patients were congenital ranulas characterized by tongue protrusion and dysphagia. Plunging ranulas were seen in 8 (27.5%) patients, and 2 (25%) of these patients were HIV infected. Simple marsupialization was done for 10 (34.5%) patients, and one of these patients had an elective tracheostomy for difficult intubation. Sublingual gland excision and with the evacuation of the cyst were done for 16 (55.2%) patients. One of the patients with plunging ranula opted for conservative management. Only 12 (41.4%) patients came for follow up: a patient had recurrence 2 years after excision of plunging ranula. Conclusion: Ranula, when neglected can cause obstructive symptoms presenting as tongue protrusion in children. Inadequate follow up was seen in the majority of the patients. Adequate follow up to determine the recurrence, especially those who had marsupialization, is most desirable.

Keywords: Management, marsupialization, obstruction, ranula


How to cite this article:
Abdullahi M, Taiwo AO, Iseh KR, Amutta SB. Ranula: A retrospective clinicosurgical analysis of 29 cases from a tertiary health institution, Northwest, Nigeria. J Clin Sci 2021;18:109-12

How to cite this URL:
Abdullahi M, Taiwo AO, Iseh KR, Amutta SB. Ranula: A retrospective clinicosurgical analysis of 29 cases from a tertiary health institution, Northwest, Nigeria. J Clin Sci [serial online] 2021 [cited 2021 Jun 15];18:109-12. Available from: https://www.jcsjournal.org/text.asp?2021/18/2/109/314450




  Introduction Top


Most ranulas are translucent, extravasation mucoceles that arise from the sublingual gland and may be quite extensive.[1] The mucus extravasation pseudocyst may be confined to the floor of the mouth (simple ranula) or extend into the cervical region (plunging ranula).[2],[3],[4]

Ranula can be acquired or congenital; most are attributed to trauma. A few are due to obstructive causes, while the causes in some are unknown.[5],[6],[7],[8]

Most patients with ranula present with gradually enlarging swelling of the mouth floor which may involve the submandibular region.[9],[10] When significantly large, ranula may cross the midline to cause deviation and/or protrusion of the tongue.[10] Ranula is easily diagnosed clinically from its location and appearance. However, ultrasonography, computed tomography, magnetic resonance imaging, and fine-needle aspiration cytology have also been used to rule out other differential diagnoses, in particular for patients with plunging ranulas.[11]

Ranula is uncommon, and few surgeons encounter more than one lesion in each year;[12] especially for plunging ranulas.[9],[12] Zhao et al.,[10] reported 580 patients with ranula over the period of 40 years, and they classified the ranula into oral, plunging, and mixed types. The oral type was the most common, and the age range of all kinds was between the ages of 3 months to 80 years.

In Nigeria, case reports on both congenital and plunging ranula have been documented in the literature.[13],[14] There is a dearth of information on the clinical profile of patients with ranula in Northwestern Nigeria.

The aim of this paper is to describe the clinical presentation, treatment, and outcome of patients with ranula, as seen in the Usmanu Danfodiyo University Teaching Hospital, Sokoto, Northwest, Nigeria.


  Methods Top


A retrospective study of clinical records of patients with histological diagnoses of ranula managed at the Departments of Otorhinolaryngology, Dental and Maxillofacial Surgery of a Usmanu Danfodiyo University Teaching Hospital, Sokoto, Nigeria. Marsupialization was performed by excising the superior wall and suturing of the inner wall of the lesion to the mucosa of the floor of the mouth. The plunging ranulas were excised by careful blunt dissection through submandibular approach. Management of ranula was also carried out through sublingual gland excision with the evacuation of the cyst intraoperatively with no intension to cyst dissection. The data were retrieved between the periods of January 2000 to December 2019 were reviewed for age, sex, clinical features, treatment, and outcome. The inclusion criteria were patients with the histological diagnoses of a ranula. The exclusion criteria were patients with other cystic swellings such as a malignant cyst, cystic hygroma, and dermoid cyst. The data was analyzed using Predictive Analysis Software (PASW) version 18.0. (SPSS Inc. Released 2009. PASW statistic for windows, version 18.0: Chicago: SPSS Inc.)

Ethical clearance was obtained from the Tertiary Hospital's Research and Ethical committee.


  Results Top


A total of 29 patients were seen during the study period. Twelve (41.4%) males and 17 (58.6%) females with a male-to-female ratio of 1:1.4. Age ranged from 3 days to 48 years (median 3 years). Most of the patients 19 (65.5%) were below the age of 10 years, as shown in [Figure 1]. Twenty-one (87.5%) patients had simple oral ranula [Figure 2], of which 8 (38.1%) of these cases were congenital ranulas. Plunging ranulas were seen in 8 (27.6.5%) patients and two (25%) of these patients were HIV infected. Eight (38.1%) patients with simple ranula presented with tongue protrusion and dysphagia, which were the main presenting complaint in children. Other presenting complaints were swelling from the floor of the mouth 13 (61.9%) and neck swellings 3 (12.5%).
Figure 1: Age distribution of patients with ranula

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Figure 2: (a) Preoperative right simple ranula. (b) Intra-oral resection of the SLG and also showing submandibular duct (SM duct). SLG = Sublingual gland, SM=Submandibular

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Simple marsupialization was done for 10 (34.5%) patients with simple oral ranula; one of these patients had tracheostomy because of difficult intubation. Sublingual salivary glands excisions were done for 16 (55.2%) patients, as shown in [Table 1]. One of the patients with plunging ranula refused surgery and opted for conservative treatment, however, the lesion ruptured without surgical intervention and the rest of the patients with a similar lesion had excision of the ranula through the submandibular approach shown in the outcome in [Table 1].
Table 1: Treatment options, complication and follow up of patients with ranula

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Injury to the Wharton's duct was seen in two (12.5%) patients who had sublingual gland excision [Table 1].

No recurrence was noted in 3 (30%) patients who had simple marsupialization before they were lost to follow up after <7 months of surgical intervention. Similarly, no recurrence was seen in 8 (50%) patients who had a sublingual gland excision (average of 3 months of follow-up). One of the two patients with plunging ranula who had excision of the ranula had a recurrence 2 years postsurgery. Twelve (41.4%) patients never come back for follow-up after they were discharged from the hospital.


  Discussion Top


Ranula is a mucocele that includes the mucus extravasation phenomenon and mucus retention cyst.[2] Most ranulas are found on the floor of the mouth and usually result from the sublingual gland.[7] It is an uncommon condition with a prevalence of 0.2/1000 in most studies[9],[10],[12] and this could explain why few cases were seen during the review period. In the present study, most of the cases of ranula involved the floor of the mouth. Zhao et al.;[10] noted similar findings: they reported only 480 cases of a ranula in 40 years. Chidzonga and Mahomva[9] in 2007, reported 83 cases of ranula in 22 years.

HIV and AIDS-associated ranula have been reported among Africans, where extensive fibrosis was found in mucus salivary glands.[15],[16],[17],[18],[19],[20] Chidzonga and Rusakaniko suggested that blockage of the salivary ducts with consequent rupture of the acini and extravasation of the mucus may lead to ranula formation,[18] this may explain the ranula formation in the two of our HIV-infected patients with plunging ranula. However, prospective studies with a large sample size are needed to verify this association in our environment.

The main treatment for ranula is surgical excision.[8] A simple surgical incision and drainage may be complicated by 100% chances of recurrence[21] and for simple marsupialization, may lead to 6%–89% chance of recurrence.[7] A complete cure of ranula is achieved with surgical excision of the ranula, where 0% to 1.55% chance of recurrence was reported.[10] However, Zhi et al.,[7] suggested conservative management for simple ranula; he reported that four of their patients had complete resolution with aspiration/marsupialization.[7] A better outcome was reported by marsupialization with gauze packing.[22] In this study, we chose to do simple marsupialization without gauze packing for 10 (41.6%) of our pediatric patients whose parents were financially handicapped for anesthesia. The children were malnourished, thus, the need for a conservative approach to minimize morbidity/comorbidities associated with sublingual gland excision. Moreover, a study has shown that complete resolution with conservative management is possible, and the resection ipsilateral sublingual gland was recommended if ranula recurred.[7]

Studies have shown the potential impact on the regression of ranula with active antiretroviral treatment;[16],[19] however, we cannot verify this effect in one of our patients who opted for conservative treatment with antiretroviral therapy because she was lost to follow-up. Prospective studies are needed to verify this claim in our environment.


  Conclusion Top


Ranula is not a common condition and may present with obstructive symptoms when neglected. Definitive management is surgical excision. However, simple marsupialization is a treatment option that needs adequate follow-up to detect recurrence. Improvement in the management of ranula in our environment can be attained by creating public awareness for early presentation and appropriate follow-up.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
McGurk M, EyesonJ, Thomas B, Harrison DJ. Conservative treatment of oral ranula by excision with minimal excision of the sublingual gland: Histology support for a traumatic etiology. J Oral Maxillofac Surg 2008;66:2050-7.  Back to cited text no. 1
    
2.
Morton RP, Bartley JR. Simple sublingual ranulas: Pathogenesis and management. J Otolaryngol 1995;24:253-4.  Back to cited text no. 2
    
3.
Langlois NE, Kolhe P. Plunging ranula: A case report and a literature review. Hum Pathol 1992;23:1306-8.  Back to cited text no. 3
    
4.
Harrison JD, Sowray JH, Smith NJ. Recurrent ranula. A case report. Br Dent J 1976;140:180-2.  Back to cited text no. 4
    
5.
Parekh D, Stewart M, Joseph C, Lawson HH. Plunging ranula: A report of three cases and review of the literature. Br J Surg 1987;74:307-9.  Back to cited text no. 5
    
6.
Morton RP, Ahmad Z, Jain P. Plunging ranula: Congenital or acquired? Otolaryngol Head Neck Surg 2010;142:104-7.  Back to cited text no. 6
    
7.
Zhi K, Wen Y, Ren W, Zhang Y. Management of infant ranula. Int J Pediatr Otorhinolaryngol 2008;72:823-6.  Back to cited text no. 7
    
8.
Sigismund PE, Bozzato A, Schumann M, Koch M, Iro H, Zenk J. Management of ranula: 9 years' clinical experience in pediatric and adult patients. J Oral Maxillofac Surg 2013;71:538-44.  Back to cited text no. 8
    
9.
Chidzonga MM, Mahomva L. Ranula: Experience with 83 cases in Zimbabwe. J Oral Maxillofac Surg 2007;65:79-82.  Back to cited text no. 9
    
10.
Zhao YF, Jia Y, Chen XM, Zhang WF. Clinical review of 580 ranulas. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2004;98:281-7.  Back to cited text no. 10
    
11.
Samant S, Morton RP, Ahmad Z. Surgery for plunging ranula: The lesson not yet learned? Eur Arch Otorhinolaryngol 2011;268:1513-8.  Back to cited text no. 11
    
12.
McGurk M. Management of ranula. J Oral Maxillofac Surg 2007;65:115-6.  Back to cited text no. 12
    
13.
Ugboko VI, Hassan O, Prasad S, Amole AO. Congenital ranula. A report of two cases. ORL J Otorhinolaryngol Relat Spec 2002;64:294-6.  Back to cited text no. 13
    
14.
Olasoji HO, Tahir AA, Arotibu GT. Plunging ranula: A report of two cases. East Med J 2002;79:51-3.  Back to cited text no. 14
    
15.
Syebele K, Munzhelele TI. Oral mucocele/ranula: Another human immunodeficiency virus-related salivary gland disease? Laryngoscope 2015;125:1130-6.  Back to cited text no. 15
    
16.
Syebele K. Regression of both oral mucocele and parotid swellings, following antiretroviral therapy. Int J Pediatr Otorhinolaryngol 2010;74:89-92.  Back to cited text no. 16
    
17.
Hershkin AT, Miller EJ Jr., Plunging ranula in young HIV patient. N Y State Dent J 2007;73:46-7.  Back to cited text no. 17
    
18.
Chidzonga MM, Rusakaniko S. Ranula: Another HIV/AIDS associated oral lesion in Zimbabwe? Oral Dis 2004;10:229-32.  Back to cited text no. 18
    
19.
Syebele K, Munzhelele TI. The potential impact of highly active antiretroviral therapy on the treatment and epidemiology of ranula in human immunodeficiency virus-positive patients. Oral Surg Oral Med Oral Pathol Oral Radiol 2013;116:e32-6.  Back to cited text no. 19
    
20.
McArthur CP, Africa CW, Castellani WJ, Luangjamekom NJ, McLaughlin M, Subtil-DeOliveira A. Salivary gland disease in HIV/AIDS and primary Sjögren syndrome: Analysis of collagen 1 distribution and histopathology in American and African patients. J Oral Pathol Med 2003;32:544-51.  Back to cited text no. 20
    
21.
Crysdale WS, Mendelsohn JD, Conley S. Ranulas Mucoceles of the oral cavity: Experience in 26 children. Laryngoscope 1988;98:296-8.  Back to cited text no. 21
    
22.
Baurmash HD. Marsupialization for treatment of oral ranula: A second look at the procedure. J Oral Maxillofac Surg 1992;50:1274-9.  Back to cited text no. 22
    


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